Saturday, 21 March 2009

Childbirth in Urban Chiapas (without footnotes)

The medicalization of pregnancy and childbirth, and the immeasurable dependence on technological knowledge rather than empirical has had grave consequences when filtered down through local systems, especially in areas of the world that are subjected to the “development” needs of the richer nations. Jordan in her explorations of obstetrical settings in lesser developed countries described a form of biomedical and technological imperialism that endeavours to replace local expertise (if it is recognised at all) rather than build upon it. In her cross cultural comparison of childbirth Jordan states: “Because of the substantial lag in the diffusion of innovation in medical practice, countries in the development backwaters of the Third World frequently practice a type of medicine that is outmoded in the very place where it was originated” (1993:185).

In all corners of the developing and industrialised world there has been a mass increase in the practice of caesarean section, more in Latin America than anywhere else, and particularly in urban areas of Mexico (Cardenas 2003). This increase falls in line with various neoliberal political economic and social factors such as more state control over individual life choices; increasing industrialisation; massive increase in urban migration (particularly in Chiapas since the mid-1990s) causing changes in customs and traditions; and unrestricted flows of information through media networks amongst other social influences. A statistical and literary study by Cardenas (2003) on the socio-demographic differentials and determinates associated with the use of caesarean sections in urban areas of northern Mexico, found that its regular practice in public hospitals may be connected as much to social political reasons as for medical pretexts: “The differential association between variables such as age, level of schooling, place of residence or ethnicity of the mother and the level of caesarean observed, such as an increase in its practice…suggest that the decision to carry [the caesarean] out doesn’t always respond to medical reasons” (Cardenas 2003:307). This observational analysis demonstrates that more qualitative research needs to be carried out with women and medical staff at all levels to shine light upon the decision making process and how this relates to political health strategy, education and human rights.

Chiapas, Reproductive Health and (Mis)Development

Chiapas has received much attention belonging to the traditional anthropological school occupied with such topics as indigenous kinship, ritual, belief systems and conflict; all essential information within its own realm but restricting discussion to a rural context and placing women as faceless, voiceless entities who are left abandoned in settlements whilst the movement and activity of men is understood through the human traffic of migration and employment statistics. Little attention (or funding) has been paid to understanding women in the rapidly increasing urban context, women of varying class and ethnic backgrounds, who, through place are experiencing access to the same health services, education and media influences. In terms of pregnancy and childbirth in Chiapas, much ethnographic information can be found about traditional practices of Mayan midwives and uses of the placenta in rural communities; but we know nothing about the urban experience of women, caught up in public health services, regarding the decision making process before and during parturition or the extent of material, physical and emotional support for the woman during pregnancy and labour (Jordan 1993). The repercussions of this lack of knowledge and misrecognition of women’s lives are played out on a grander scale through the political manipulation and misdirection of global health strategies which work to promote technological advancement as a way of population control and improving mortality statistics.

The World Health Organisation (WHO) define reproductive health as the opportunity for all people to live a satisfactory and safe sex life, and have the opportunity to reproduce to their full capacity: a couple can freely decide if they want to reproduce or not; when and how often to do so, and have access to services and appropriate healthcare so that the pregnancy results in the survival and well-being of the mother and infant (Rio et al 2003:182). This definition has been carried over to more localised development aims, such as the Panamerican Health Organisation’s Health Initiative for Indigenous Populations 1993 and National Health Programme introduced by each Mexican Federal government and that since the Fox government of 2001 has incorporated the global aim of reducing maternal and infant mortality rates related to pregnancy and childbirth. The objective of such programmes as Arranque Parejo a la Vida with its emphasis on early detection of complications through the use of technology have been translated and manipulated by health services on a local level to what is tantamount to what Castro and Erviti (2003) have described as serious violations of reproductive rights.

This narrow vision brought down from global analysis has quickly translated into coercive politics, numerous ethical violations and inefficient results for programmes (Rio et al 2003:181). The same reproductive health technology, such as foetal heart monitors and ultrasound, produce information used for analysis and over time to create ‘norms’ that women’s bodies (and the foetus) should conform to throughout the pregnancy and right up to the decision of birthing method. As shown through her comparative studies of childbirth in four cultures, in a North American hospital Jordan (1993) found through observations in labour rooms that such knowledge produced by technologies cannot be relied upon, and does nothing but work against experience knowledge of the (woman’s) body.

The focus on Caesarean Section in Urban Chiapas

In 2007 an explorative investigation into medical attention in childbirth affecting indigenous migrants to urban areas and public health policy was carried out by Nazar et al (2007). This study also makes comparison with mestiza women living in areas of social exclusion who are likely to be using the same health services. In the period of the study, alongside an increase in births attended by institutional medics, a decent in the frequency of vaginal births was registered in both the mestiza and indigenous population. Nazar et al state that in these two cities in Chiapas alone from the period 1979 - 2003 the practice of caesarean section has increased almost nine times (870.0%) in the mestiza population and almost four times (394.1%) in the indigenous population.

The authors question the fact that WHO initiatives working towards decreasing maternal mortality rates, are having little if no impact on a local level due to medical practices and attitudes towards women of particular ethnicities and social background. The results of Nazar et al’s paper indicate that a huge increase in the use of caesarean section (which according to Cardenas follows medical trends in the ‘developed’ world) and increases in the use of Government Health Sector Services are actually counteracting any effort to improve maternal mortality. As such, if the practice of caesarean has been adopted as a strategy to curb mortality rates, this makes very little medical sense whatsoever, let alone the ethical debate of violating women’s bodies in this manner.

Caesarean birth carries great risks for both mother and infant. Risk of death (for the mother) is higher in the case of caesarean compared with vaginal birth…and the health of a newborn also can be negatively affected…Studies carried out in India (…), Malaysia (...) and Nigeria (…) show an increase in post-birth and neonatal mortality in infants born through this method (Cardenas 2003:303-05). The data analysed by Nazar et al adds to the essential debate over women’s rights over their bodies, treatment by the medical sector of indigenous women and women of deprived social backgrounds, quality of reproductive health education and attitudes to the cultural cosmology of birth within ‘development programmes’ and neoliberalistic attitudes of the body, self and what constitutes as natural.

One can argue that the WHO’s mission to achieve equality for all people through social, physical and mental wellbeing is a political project within itself and is open to varying cultural definitions on a local level. Or alternatively, open to varying social, political and economic consequences out of which is then created the ‘norm’ in that specific society; that is to say on a service provision level which often clashes with actual daily cultural behaviour. Global health initiatives have allowed scientific knowledge and its associated technologies to dominate local cultural values, effectively removing natural phenomenon and infringing seriously on women’s rights. The very nature of medicine as a science allows this discreet domination of the masses to take place, as stated by Latour: “Scientific knowledge purifies the mobilisation of cultural values whether they be religious, political or economic” (cited in Ayora 2002:116). Although development initiatives often have the public face of taking into account or respecting local cultural values, within health service provision this is counteracted by the ability of (western) medicine to transcend cultural values and be transferred to any given culture at any given time, placing its own values as dominant.

Medic v’s Midwife

In their analysis, Nazar et al noted a large shift in confidence leaning towards the medical attention for childbirth rather than the traditional use of midwives: “…it is important to emphasise that 94.1% of the mestiza women and all of the indigenous women who were attended by physicians said they did so because they had more confidence in the medical training of the physicians than that of the midwives, which in conjunction with the tendencies observed, shows evidence of a displacement of values towards allopathic medicine as much with mestiza women as with indigenous” (Nazar et al 2007:769).

Unfortunately there is no analysis available to suggest how and when the reputation of midwives began to take a backwards turn, or as to what opinion the medical profession have on midwives. Under political consideration midwives are openly accepted in rural areas where the government or NGOs fail to reach with institutional medical care. They are however in these cases given medically designed training by government programmes to bring their practices ‘up to date’, registered into the system and generally told to refer ‘complicated’ pregnancies to urban clinics (Jordan 1993; Ayora 2002). This toleration of traditional practices within certain spaces still reiterates that contemporary medical knowledge is paramount and that there exists a huge power imbalance between knowledge practices. To date I am yet to find evidence of midwives and their essential skills being employed alongside medics within institutional settings in Chiapas.

Conclusion: Women, Pain and Modernity

To conclude I would like to consider a very complex side to the increase in caesarean sections in Chiapas: the issue of women requesting this surgical procedure themselves. Even without empirical evidence, one would be safe to assume that as well as not every birth in urban Chiapas ends in a caesarean section, neither are many of those that do forced against their will. Many women in urban Chiapas (and Mexico) actively request birth by caesarean for a variety of reasons; an important question arising from this is what is the woman’s rationality behind making this particular decision? And as I mentioned in the introduction, in the many cases where women opt for caesarean section when a vaginal birth is preferable, at what level are they complying to the maintenance of the systems of power that oppress them? I am aware that this question in itself is worthy of discussion in much greater detail than I provide here, my intention is to bring forth questions for further consideration and attention to an aspect that I believe plays a role the increase in childbirth by surgical interference.