Thursday, 4 October 2012

No you can't choose your midwife but you can choose a caesarean!

If I were to explain that within six months you would no longer be able to choose a midwife who you and you family could build up a relationship with over 9 months, have a home birth without uniforms and bizzare multi-presence protocol and not be pressured into sonograms you don't need and a birth plan that has your wishes at the centre, you may wonder: "Did I ever have this choice in the first place?" ...

Yes, it is actually possible to birth outside of the NHS and no they didn't invent it! There has always been this choice in the UK, independent midwives (IMs) have worked before, during and after the NHS and state manipulation of midwifery and have provided individual woman centred care for ..well I could say centuries, but to be more exact since time began! Women have always had the option to opt-out of the system and hire (its not as expensive as you would think and therefore not just the reserve of the middle classes as is it is often viewed) a woman to support them during the pregnancy, birth and post natal period. IMs have lovingly dealt with all aspects of fear, trauma, post-natal depression etc. and do so by providing as much time as you need, not a 5 minute slot in an over-run surgery. 

Until now that is, independent midwifery (IM) in the UK has been serious threat for around 5 years or so. I won't go into the legislative attack on IMs in this post, much better detail can be found by clicking in this link and also a brief search on the net. But lets say in short that by 2013, unless they work for a supporting company who can provide funding for exorbitant insurance fees rising over the price that any individual could afford (around £80,000 and rising) then its bye bye birthing practice. Their only choice (ahem!) is to join the ranks of the uniformed NHS and do it their way. Nice strategy government body people to populate a dwindling NHS profession - force IMs into your service!! Without that IMs can work as doulas, a noble art and invaluable role to all women and families - but invaluable as support to woman and midwife. It's basically saying "look we know you're qualified, have many years of experience and are more caring than any nameless institutional drone will ever be BUT you just have to watch and you don't get to say when!" Strangely enough a bit like NHS midwives when an obstetrician enters the labour room!

Now before I get too carried away, I wanted to write this post not so much from my usual activist and anthropologist view (although they'll get in there somewhere!), but from a woman and mother's point of view. I write a lot about the problems in Chiapas and Mexico and feel strongly about the treatment of women there, however, I also take great pride in having lived there, married there and started my family there - with the subjective freedom to search out and identify the support and services that I needed. I gave birth to my second child in the UK and although there are just as many stories to the contrary as to support mine - I NEVER WOULD AGAIN if left to the mercy of a public system that has no respect for the divine wisdom and magic of original midwifery. No matter where I am in the world as a woman I know my own body and I know its limits. As a mother I trust in myself and my baby to find our way through together and to listen to what we are thinking/feeling/doing. Whether in a challenged, post-colonial economy or a fucked up British one I feel it should the right of any woman to seek her own education about reproduction, birth, abortion and make her own decisions about what happens with her own body. It should be the right of any woman to birth the next generation in a safe environment with those she loves and respects close by and no stranger touching her who doesn't even bother to ask her, her name. 

The current system in the UK is striving to offer women more choice (ahem!) birthing centres next to hospitals, elective caesarean, perhaps a home birth if you, your baby, your home meet the criteria. Whilst activists for reproductive rights are fighting for the right to choose (ahem!) interventions and surgery on the basis that no-one should suffer in modern day (without considering that if most pregnancies and births are taken out of a pathological model and medical birthing environment the 'suffering' would not so much be an issue).

So reading between the political spin and woeful lack of media coverage (as expected on women's health issues) you can shortly feel free to elect for surgical interventions that can lead to long term complications, problems with breast feeding, institutional challenges to follow-up vaginal birth, drugs in yours and your baby's system a big fat scar and an obstetrician who doesn't know your name but may charge you a small fortune when they eventually kill off maternity services from the NHS. BUT YOU CAN NOT FEEL FREE TO choose whom you wish to attend you based on whether you like their personality and approach to pregnancy, get to know your midwife and they you and your family over 9 months, decide where you really want to bring your baby into the world and receive support that enables you to feel empowered and in control of your reproductive destiny so that suffering is not a concept (managing pain yes, suffering no). On rare occasions you may fall into an NHS postcode that supports this type of midwifery practice in the system, but that's not a choice (ahem!) its the luck of the draw - lucky you!

Midwives are amazing and many in the system are just as amazing as those outside it, but here in my country of origin I don't get to decide any more which one I want to allow into the most personal, naked, precious moment of my life and I am no longer able to say please don't put your fingers inside my vagina stranger person as I do not wish to have an internal examination if you show me I can do it myself......quite frankly that sucks!

Wednesday, 1 August 2012

Death Threats, State Violence = Bad Reproductive Health Care

My response to this short  online news piece in relation to violent societies appears below in English:

México: Exigen protección para periodista Lydia Cacho

El Comité para la Protección de Periodistas se manifestó sobre las nuevas amenazas de muerte que la periodista y defensora de derechos humanos Lydia Cacho recibió el pasado 28 de julio debido a su labor informativa.
Cacho se encontraba escribiendo en su estudio cuando recibió la advertencia: “No te metas con nosotros o te vamos a mandar a casa en pedacitos”.
El mensaje fue filtrado a través del sistema de radiocomunicación instalado en su casa en Cancún, informó la organización.
La Comisión Interamericana de Derechos Humanos (CIDH), en 2009, otorgó medidas cautelares a la periodista tras darse a conocer varios actos de vigilancia e intimidación por parte de hombres armados.
Article19 también hizo un llamado al Estado mexicano para que se hagan efectivas  las medidas dispuestas por la CIDH para proteger a la periodista.
Según Article 19, Lydia Cacho ya se encuentra a salvo fuera de la ciudad de Cancún.
Apart from highlighting the power of social media this news piece is just one amongst many that demonstrates the normalisation of violence in Mexican society. Sometimes I find it difficult to write about direct violence in Mexico and/or in Chiapas more specifically because I worry about being complicit to a polemic that can have negative results and stereotype a nation.
Although I am always aware of what can happen and have evidenced some violent and dramatic scenes during my time in Mexico, I have experienced love, community solidarity, trust and respect on just as many levels. I supposed this comes down what I have always written about Mexico - it is a country of mega extremities - when it is good it is amazing and when it is bad it is horrific. At least with that you always know where you are.
The article above is in relation to investigative journalist Lydia Cacho (@lydiacachosi) one of Mexico's most hard working, consistent and brave women who writes about and speaks out for women's rights and anti-corruption. 
In brief she was kidnapped by public security and arrested in 2003 for writing articles and later a book called Los Demonios del Edén (The Demons of Eden) which included narratives of abused girls and named men involved in a paedophile ring. In 2006 she published a book on the impunity and femicide in Cuidad Juarez of which she continues to be very vocal today. And now according to reports she is being threatened again by not so brave cobardes who shout anonymous threats from hidden places. 
The suspected involvement of local politicians and security forces on previous violations of her human rights to live unharmed and peacefully as any other citizen of the world must make it difficult to know who to trust. My ears always prick up at the mention these stories of journalists in danger in Mexico as this is the career my husband once chose, for which he too received threats and witnessed corruption on a regular basis - albeit on a smaller scale. I remember the BBC once reporting that Mexico was second to Iraq in being the most dangerous place in the world to be a journalist, I remember it most vividly because at that time I was back in the UK fearing that I might never see my life partner again. He lost faith in the world of journalism because of his junior experience and vowed never to return to it. It appears that as with everything in that amazingly, dramatic and lively country you are left to choose between extremes - be part of the corruption that only prints what the politicians and high end society tell you to or stand against it and have you and your family receive regular death threats and at worst be murdered.
I wrote and presented a paper at the end of 2011 about gendered violence and reproductive healthcare in Chiapas. In this paper I began to explore the notion of how high levels of violence in society reflected not high levels of structural violence but direct violence in reproductive healthcare settings. This was followed up earlier this year by another paper presented on Barcelona and a following article  (all published in edited versions on this blog) on the impact of militarisation on gendered violence and reproductive health. 
As disturbing as continued reports of violence, impunity and corruption in Mexico are in the world media are, they serve to remind me that hopefully I am not alone in thinking that part (though not all) of the catalysts behind the poor treatment of women during pregnancy and labour, and in health services in general, are connected to the wider violent actions (and acceptance) of a society. 
A more important reason personally to pay attention to violence in Mexico, without sensationalising and demonising a nation is precisely because my extended family, children, friends and strangers that I have experience of cannot be further (in the extreme) from this phenomenon. 

Sunday, 22 July 2012

Reviewing writings from the Past

Prompted by a recent Twitter thread I have published an edited version of my MA thesis on this blog ( and also as a note on

I wrote the original thesis entitled : Multiple Gender Identities of the Isthmus Zapotec and the Transition of the Household into a Neoliberal Mexico back in 2006. As well as the submission for my MA in Social Anthropology is was also intended as the project for my first attempt at gaining a PhD (which turned into a major disaster but that's for another time and place!).

Photo from
Re-reading, editing and re-posting sections of this thesis has presented me with some opportunity for reflection. The original tweet thread from @icdad and @ThinkMexican reminded me of the months of thinking, reading and writing about the complexities of gender and sexuality constructions in Latin America I had done, that now seem a distant past. Just what happens to all that stuff we learn in our early academic and educational journey? Does it just get compartmentalised, archived in the memory banks until prompted by an external force to come to the fore again? 

Surely on many levels this previous knowledge hoard must inform my thinking and understanding of the world today? I just don't spend much time reflecting upon it.... I now realise that is a shame.

As well as a reminder of my first in depth anthropological thinking into gender and economy, reading this thesis has demonstrated en evolution in my writing. It's difficult to read academic work from the past, it makes me cringe - I admit to never revisiting my undergrad assignments - I don't think I have the stomach for it! Opinions and ideas without much substance is a polite way to describe my undergrad self... What I would probably now write on my own student's feedback as "This discussion has some potential, however..."

I think perhaps its a good idea to have a reunion with my past self every now again, catch up with how I arrived at my current state of being and maybe learn a few things about where I'm going! 

Monday, 2 July 2012

If I could draw my PhD....

If I was able to express in art what I'm trying to do by analysing what is inside and how women feel it would look like this:

Salvador Dali City of Drawers

If only I could embody Salvador Dali that is!

This last couple of weeks I've been trying to get to grips with pregnant embodiment via a multiple body analysis (using Lock and Scheper-Hughes' notion of Individual Body, Social Body and Body Politic). I'm finding that as with theories of embodiment themselves I am awash with mental imagery and physical feelings of what it is to embody a social (and cultural) idea of what reproducing is and what having an occupied womb feels like. What I'm finding most problematic is turning this into something tangible, that makes sense to those outside of my head who are given the task of deciphering what it is I'm trying to say. 

Studying the humanities (or social science - when it comes to anthropology no-one can decide!) has introduced, rejuvenated and reaffirmed a love for artistic expression. I'm finally able to connect how humans have coped with a lack of the right words to describe how they feel - what they have done with a burning desire to express how they experience the world. Making me at once liberated and dismayed that no matter how much I would like to dance my way through a viva voce I will never be allowed.

I have discovered one saving grace though, the work of Julia Kristeva  and her writings about poetic language and the semiotic chora (the pre-lingual subject in process). From what I can begin to understand is that she is willing to explore the pre-cultural human in the womb, ourselves before we become social selves. This entails trying to grasp what urges are and can be - if there is any chance that some part of us cannot be explained via the route of social construction. 

I spend so much of my time thinking about how our every thought and feeling is manipulated by our surroundings and experiences - a very European approach to a world we have perhaps lost touch with, a spirituality that has been analysed away. Kristeva has bought something back for me, in a way given me permission to think through my own birth experiences and those of others. To be able to dig deep into other cultures and narratives that celebrate a female, maternal, real, connection to the earth - a way of metaphorically kicking off my shoes and feeling the earth or sand in between my toes. I can close my eyes and see liquid, blood, organs, space and what I imagine to be the collective wombs of women around the world, I can imagine myself swimming through dark, sticky red liquids that relate to womanhood and reproduction.

If I only I could find the right words......

Sunday, 17 June 2012

Birth Story

 BIRTH STORY: Ina May Gaskin and The Farm Midwives is racing toward the finish line with finishing costs mounting--seeking women and men who share our enthusiasm for what Ina May and the Farm Midwifery clinic have achieved in the last 40 years; since the 1970s these counterculture heroines have inspired hundreds of thousands of women to believe in their bodies’ natural ability to birth safely and beautifully. Today, with nearly one-third of all U.S. babies delivered via c-section, their knowledge and skills are more needed than ever.

This amazing film project has been put together by two women who describe themselves as "two filmmaking mothers who have been inspired by the important work of world-famous midwife Ina May Gaskin and her incredible colleagues. We've spent the last two and a half years juggling cameras, microphones, hard drives, preschool drop offs, nursing infants, pregnancy, editing schedules, babysitting schedules, American express bills, and vomiting four-year-olds"...

It seems to me that in 2012 we are really racing towards positive change and realisation of just how important respectful birth is and how we treat birth reflects how we are as a society as a whole ... 

Saturday, 16 June 2012

Anthropology contributing to the World...

Here is a link to my latest post and part report on my sister blog from the RAI conference Anthropology in the World Conference in London: 

I attended a great panel on anthropology's potential in the environment of security studies, this timed perfectly with the paper I've been writing (see previous June post) about the long term effect on conflict in Chiapas and reproductive health services. It also reaffirmed by belief in what ethnographic methods and anthropological theory can contribute to revealing the lived experience of people. Especially when all we get from projected media images are scenes of violence and fear to keep us away. It is often so easy to forget that individuals and families continue to live daily in these environments and continue to have the same food, shelter,water, employment, relationship issues that exist in places of relative peace. Collecting, representing and reflecting upon the stories of others reminds us to look beyond the situation to the people involved in it. 

Saturday, 2 June 2012

Conflict and Reproductive Health in Chiapas, Mexico: disappearing the Midwife

This paper is currently under review (and this is a shortened version)...please contact me before referencing :)..... 

Women's voices are represented in this paper all names have been changed and all interviews/data collection occurred with informed consent.

Ooh and the footnotes are out of sync due to my own technical limitations.. but they are at least there!

As always comments greatly received!!

Keywords: Chiapas, militarization, obstetric violence, bio-politics, urban midwifery

This paper aims to demonstrate how the impact of low intensity armed conflict and associated structural and direct violence in the Chiapas region is reflected in the interpretation of reproductive health policy and practices, manifest in the treatment of women during pregnancy and birth[1]. Drawing upon critiques of neoliberal economic logic and bio-politics in the context of Latin America this paper will analyse how policy in everyday life exposes mechanisms where local practices and global forces impinge on the body. This type of analysis illustrates the ‘body’ of the state and the ‘body’ of the pregnant subject as entangled and inseparable. With this in mind I will also propose the argument that current policy and obstetric practices not only exacerbate gender inequalities in the society as a whole but also actively promote the disappearance of midwifery practices in urban locations; a female dominated and woman centred practice currently outside of state infrastructure.

    Chiapas has been the focus of intense development over the last decade, much of this work justifiably targets rural areas that are most affected by severe economic and social inequalities and most visibly affected by the ongoing conflict. It can be argued that little work has been done in this area in terms of measuring the impact of the militarisation and paramilitary violence that continues alongside the development of targeted access to healthcare and cash transfer welfare programmes in rural areas. It appears to be an effective strategy that by moving military presence from the public eye, acknowledgement of the violence associated with militarization is disappears with it.  The intention within this paper is to continue the well documented discussion about the associations between conflict, State violence and reproductive health inequalities in Chiapas, but move the focus from the rural to urban sites where my research up to date suggests very little attention has been paid. This is particularly true of informal and private health networks and midwives.

Intersections of Violence

In the wider context of Mexico a intersecting relationship can be observed (in academic literature and media reporting) between neoliberal policy violent States, militarization of urban cities of the north and high levels of maternal and infant mortality, and also reproductive rights violations such as unnecessary caesarean section rates, contraception or sterilization without consent and refusal of legally approved abortion[1]. The aforementioned violations of reproductive rights are understood in context with this paper as defining what I shall term as obstetric violence. As Jenkins remarks, ‘the notion of violence is both much contested and multiplex in form’[2]. There is no agreed definition across literature in a global context for violence perpetrated by health or medical workers although it occurs under similar social and structural conditions a cross-cultural definition of violence can be problematic due to cultural perceptions of gender roles and bodies. It is important for the purpose of this paper that obstetric violence - although a problematic term in relation to much feminist discourse and anthropologies of violence - is understood as specific to a type of gendered violence that happens as a consequence of already existing, wider structural violence. In both Latin American and Spanish literature and birth activism Violencia Obstetrica is a widely used and accepted term describing acts and situations that relate to the descriptions given by women and professionals in my own research.
Labelling aspects of legitimised health practices as violence could be easily contested, but my experience in Chiapas has shown that line with Castro’s work in Mexico City hospitals that: ‘for many women, a caesarean section that could have been avoided is a violation of their bodily integrity, just like having a routine episiotomy, epidural anesthesia without consent, non-indicated oxytocin induction or augmentation, multiple and painful vaginal examinations...[and] needless exposure of sexual parts in common labour rooms...’ culminate in practices that can be defined as obstetric violence[3]. My understanding of these practices as violence is also informed by philosophical argument, Parsons who in defending violence as a social phenomenon writes that violence is recognised when ‘occurrences or outcomes were avoidable or could have been prevented’[4]. This is particularly useful for challenging much medical argument that defends practices as necessary for saving lives, when it is more often as a result of institutional restraints, unchanging and unchallenged medical education, social and political pressure, budget and resources, policy targets and cultural attitudes towards pregnant bodies, or more eloquently labelled by Castro et al as the ‘Iatronic Epidemic’.[5]

Conflict and Health Implications in Chiapas

“Birth is like a battle of the ancient Maya, it’s bloody and painful, you either live or die! You must prepare yourselves to do battle!”[1]

Given the more recent attention given to militarisation, high profile murders and other drug 

related violence and crime in northern states, the continuing militarisation of Chiapas and its associated 

affects of violence in everyday practice receive little attention. The focus instead has been on development 

strategies to deal with the state’s poverty status and high mortality rates. The attention given to improving 

mortality becomes distracted by an interpretation that access to clinical health care is the solution. Research 

has shown that the problem of high mortality does not lie only in access to hospital delivery or resources. It

has been reported that avoidable deaths, unexpected complications in labour and complaints about treatment 

occur in cities where an overwhelming majority of births take place in hospital and relatively well resourced 

facilities[8]. This raises questions about violence and power relations in obstetrics and the current strategies 

to improve maternal mortality in the region including coercive welfare programmes that require women to 

receive medical management of their pregnancy and to give birth in a clinic.

          It is estimated that over 12,000 civilians have been forcibly displaced by a combination of military and village level factors since the conflict began a large proportion of which will have fled to inner and outer State urban areas[9]. Although there are no exact statistics available in terms of inner-State transmigration records of access to health and welfare services and demonstrate large scale change to urban demographics and cultural make up of cities[10]. Economic influence and cultural changes in rural communities also contribute to greater movement of lone female indigenous migrants in particular who will travel to urban sites for work, study or social exclusion from their communities. The failure to analyse the impact of conflict on urban sites in Chiapas is significant, there appears to be a seamless transference of bodies and practices from one completely different environment to another. This is an aspect that goes unquestioned and unconsidered by health policy and practice that adopts the universal application of medical strategies to its problems and does not take cultural complexities and wider societal impacts into account. Many women who use public and private services will have experienced some level of direct or structural violence throughout their lives. 

   Obstetricians and their professional support staff are more overtly authoritarian during actual birth situations and/or very soon after birth has taken place, when on either occasion a woman can be at her most vulnerable and without familiar support networks[12]. It appears that where there is more professionals present and collective hierarchies stronger overt coercion and repression becomes stronger. The following comment from Rosie (30 years, mestiza, teacher) is typical of many women who were pressured into IUDs directly after giving birth:

“…straight after my son was born, in the moment the placenta came out…he said ‘you miss, you will die if you have another baby’, at this moment I didn’t know what he was talking about , we’re going to put an [IUD] in, and I said  ‘no, no doctor’ and he told me to decide and as I said no he said ‘well miss, you are an irresponsible woman, you want to bring another baby into this world and to put it into danger’ , he said ‘you are a bad mother because you want to make another baby suffer, did you not see how much you made this one suffer?’... I didn’t understand perhaps in this moment so I said ok, I just wanted some peace and quiet so I just accepted it”.

   Doctors interviewed in previous studies with similar findings in Mexico City hospitals defended such behaviours and argued a logic that women are there to ‘cooperate’ with the physicians, or ‘be good patients’[13]. Such treatment can be argued to be part of the institution frameworks and embedded in the history of medical education, but medical professionals do not work in a vacuum separated from societal influences and local contexts. The questions must be asked as to what are the wider societal factors that facilitate such violations and normalise the treatment of pregnant and birthing bodies in this way. How does violent conflict manifest in daily social life in Chiapas that contributes to informing attitudes about bodies, risk and mortality? Moreover what part does health policy and practice play in facilitating the defence of violations of reproductive rights via arguments of necessity?

 Population Control and Disappearing the Midwife

In line with commitment to MDG5 the Mexican government are committed to improving maternal mortality and access to reproductive health services for all women. Increased access to institutions, particularly in urban areas has resulted in a figure of 94% of recorded live births taking place in hospital (WHO 2011) . In terms of a development model this is taken as an indication that increasing numbers of Mexican women are receiving skilled assistance at birth and are accessing some form of antenatal care. World Health Organisation indicators using data from 2000-2010 estimates that 36.9% of all recorded live births in hospital are by CS[14][15]. Whilst this percentage does provide evidence of increased access to skilled birth attendants and antenatal care, the overall improvement of maternal mortality figures that health policy and practice has as its target fails to decrease at a rate anywhere near as significant. According to a recent systematic review maternal mortality in Mexico has decreased by 1.9% every year between 1990-2008 compared to a decrease of 3.9% in Brazil[16] which is significant as both countries are amongst the highest rates of CS in the world and rising.  Researchers carrying out studies on the growth of CS in developing countries (of which Mexico was included) recorded no reductions in maternal or neonatal mortality and morbidity when frequency of CS was more than fifteen percent[17] . The south east State of Chiapas provides an interesting case and argument for looking beyond statistical evidence to women’s experience. In comparison to the northern states where both rates of structural and direct violence could be linked to rises in CS and hospital birth, Chiapas muddies the water somewhat due to its geographical location and population dynamics. Chiapas is reported as having the highest maternal mortality rates in the country, lowest incidences of CS and 74% of births are attended by a midwife meaning that those 74% of recorded births take place outside of the hospital as midwifery is not currently practiced or accepted as a professional role inside medical institutions[18]

High maternal and infant mortality figures culminate in Chiapas being a federal target for achieving MDG5 and coverage of cash transfer welfare programmes. At the beginning of the twenty first century when MDGs were first introduced, the WHO centred its maternal mortality strategy on universal access to antenatal, birth and postnatal care, the term Skilled Birth Attendant was also introduced. It can be argued that at this time a shift in maternal mortality policy language and behaviour (from support for traditional birth attendants to the woman’s access to services) marked a specific move towards medical interventionist models and local State control over who may be defined as a Skilled Birth Attendant. In keeping with this policy shift there have been more recent developments in terms of professionalising midwifery and those who identify as traditional birth attendants (TBA)[20], to become Skilled Birth Attendants recognised by the state or partera professional[21] in local terminology, therefore serving to further delegitimize the position of TBA. This approach also wrongly assumes that TBAs don’t have medical knowledge or training to deal with complications or identify at risk pregnancies and denies any previous collaborative work done between state governments, NGOs and TBAs. Through this policy shift in Mexico the term partera (midwife or directly translated - she who attends birth) is appropriated by those who decide what training and licensing makes such a position. It is not clear as of yet who someone without the proposed professional qualification yet continues to attend women in her community will become in terms of public presence and title of legitimate partera.

    It is worth noting briefly that the Mexican cash transfer welfare programme (currently titled Oportunidades) relies upon coercion and compliance. It aim is to improve the education, health, nutrition, and living conditions of population groups in extreme poverty and to break the intergenerational cycle of poverty.  In the area of health the programme offers an essential health care package that includes pregnancy and delivery care for women enrolled in the programme[22].  Attendance at the health promotion talks and medical checkups are a requirement for being registered on the programme and receiving financial benefits. The woman must also give birth at a designated clinic in order for her child to be eligible for financial support under the same scheme. The search to improve maternal health and birth outcomes has led to an almost complete medicalisation of pregnancy and birth based on a dominant interventionist model[23]. I have found that in existing literature and in my own data I am met with a wall of policy that legitimates the appropriation of birth experience from thousands of women and acts as the catalyst for violence of varying kinds. State intervention based upon social economic status appears to affect every aspect of the pregnancy and birth outcome and illustrates the complexities of a pregnant body and what it can represent. The pregnant body is constantly shifting in its context, it is at every stage a social product and its treatment reflects the attitudes of the wider society in terms of respect for life and women’s social position. The coercive nature of conditional cash transference programmes impact dramatically in terms of behavioural and cultural change. The conditions of compulsory attendance at a named clinic for all antenatal, perinatal, actual birth and postnatal attention illustrates how this kind of State care, despite good intentions to address statistical gaps in birth outcomes is disruptive of more traditional social and/or woman-centred models of pregnancy and birth support.  They are also dismissive of the wider social networks of support a woman normally receives during her reproductive lifecycle.

 Resistance and unresolved issues

    It has been shown in studies that women in rural areas in Mexico prefer when given the choice to seek pregnancy care from traditional attendants it is not clear from current data whether this differentiates between attitudes to antenatal care and actual birth attention[24] . Although this behaviour is changing due to the growth of cash transfer welfare programmes and building of new hospitals and clinics equipped for high intervention birth – it highlights a strong presence of midwifery practices and social norms about the use of midwives as opposed to medical attention in most healthy childbearing situations, at least in a rural context. The subject of urban midwifery and women’s attitudes has of yet been given much attention in Chiapas, a few isolated studies do however exist on a national level[25] and begin to straddle to rural-urban divide. Women report to attending clinics for care and birth because of the conditions of their health insurance or welfare benefits for example, if in receipt of social insurance through employment (either private, State or Federal) they must attend antenatal appointments in order to receive any support required at birth or postnatal. Those in receipt of basic social assistance must attend all appointments and birth in a designated clinic in order to continue to receive the benefits or so that their new born child will have entitlement to basic welfare.  This means that no matter what level or quality of treatment the woman is receiving she is obliged to attend or be penalised. Where there is already a well documented culture of abuse in reproductive health practices and gendered violence in medical institutions coercing women into treatment can only encourage further violation without much fear of reprisal[26].

   The overarching aim of policy and development programmes is to improve life expectations for both women and babies, but the lack of distinction in regards to the quality of treatment and recognition of the woman’s experience has serious consequences in regards to local practices and dominant medical discourse. In this paper I have combined analysis of existing literature and my own field notes to explore the argument that global scale management of health problems and population control fail to take into account where conflict impacts significantly on local attitudes, experience and behaviours. I propose the notion of disappearing the midwife to describe how a woman’s only choice in the urban context is to receive medicalized management of her pregnancy and birth – a model that openly rejects the concept of midwifery as valid knowledge – is actively working to rid the society of its cultural, woman centred birth practices. By not recognising her as a legitimate form of care for pregnant women – the urban midwives are practising in hidden spaces and have effectively disappeared in terms of a social presence and from reproductive health discourse. Obstetric violence understood as a consequence of structural and direct low intensity conflict violence and committed to maintain power relations between genders continues to be a major global health problem– the normalised violent practices that many women are subjected to in pregnancy and childbirth translates to a situation where universal attempts to improve health exacerbate rather than improve the problem.  Ongoing and ignored conflict in the region only serves as a catalyst for such violence to be maintained.

[1] How one head consultant in an urban public clinic described birth to a group of women in the compulsory antenatal education classes, author’s field notes March 2008.
[2]Brentlinger et al., 'Pregnancy Outcomes, Site of Delivery, and Community Schisms in Regions Affected by the Armed Conflict in Chiapas, Mexico',  (, Nazar a B, Salvatierra Bi, and Em, 'Atención Del Parto, Migración Rural-Urbana Y Políticas Publicas De Salud Reproductiva En Poblaciòn Indígena De Chiapas, Mexico',  (, Physicians for Human Rights, 'Excluded People, Eroded Communities: Realizing the Right to Health in Chiapas, Mexico', in El Colegio De La Frontera Sur (ed.), (El Colegio de la Frontera Sur, , 2006).
[3] Secretaría De Salud, 'Búsqueda Intencionada De Muertes Maternas Y De Menores De Cinco Años, Y Registro De Nacimientos En Los 101 Municipios Con Bajo Índice De Desarrollo Humano', in Secretaria De Salud (ed.), ( 2009).
[4] Brentlinger et al., 'Pregnancy Outcomes, Site of Delivery, and Community Schisms in Regions Affected by the Armed Conflict in Chiapas, Mexico',  (
[5] Ibid. Shannon Speed, Rights in Rebellion : Indigenous Struggle and Human Rights in Chiapas (Stanford, Calif.: Stanford University Press, 2008) xvii, 244 p. : ill. ; 24 cm.
[6] Graciela Freyermuth, 'Desiguales En La Vida, Desiguales Para Morir. La Mortalidad Materna En Chiapas: Un Análisis Desde La Inequidad', in Programa De Las Naciones Unidas Para El Desarrollo (ed.), Informe sobre Desarrollo Humano en Chiapas (CIESAS-sureste, 2010), Monica Trujillo, Amado Ordonez, and Rafael Hernandez, 'Risk-Mapping and Local Capacities: Lessons from Mexico and Central America', Oxfam Working Papers (Oxfam GB, 2000).
[7] Graciela Freyermuth, 'Evaluación Del Subregistro De La Mortalidad Materna En Los Altos De Chiapas Mediante Las Estrategias Ramos Y Ramos Modificada', salud pública de méxico, 51/6 (2009). World Health Organisation, 'Rising Caesarean Deliveries in Latin America: How Best to Monitor Rates and Risks', (World Health Organsiation, 2009).
[8] D'oliveira, Diniz, and Schraiber, 'Violence against Women in Health-Care Institutions: An Emerging Problem',  (:1681
[9] Brentlinger et al., 'Pregnancy Outcomes, Site of Delivery, and Community Schisms in Regions Affected by the Armed Conflict in Chiapas, Mexico',  (
[10] Nazar a B, Salvatierra Bi, and Em, 'Atención Del Parto, Migración Rural-Urbana Y Políticas Publicas De Salud Reproductiva En Poblaciòn Indígena De Chiapas, Mexico',  (
[11] From author’s field notes August 2011. 
[12] In most public hospitals only the woman and medical staff are allowed in the delivery suite.
[13] Castro and Erviti, 'Violations of Reproductive Rights During Hospital Births in Mexico',  (
[14] Estimation is required to correct for under-reporting of c-section deliveries in private facilities.
[15] Who, 'Estadísticas Sanitarias Mundiales', in Who (ed.), (World Health Organisation, 2011).
[16] Margaret C. Hogan et al., 'Maternal Mortality for 181 Countries, 1980–2008: A Systematic Analysis of Progress Towards Millennium Development Goal 5', The Lancet, 375/9726 (1609-23.
[17] Fernando Althabe and José M. Belizán, 'Caesarean Section: The Paradox', ibid.368/9546 (1472-73.
[18] Citlali López, 'Proyectan Escuela De Parteras Para Abatir Muerte Materna',,  (April 4th 2012), Who, 'Mexico: Country Profile Maternal Mortality, ' WHO Director-General Roundtable with Women Leaders on Millennium Development Goal 5 (World Health Organisation, 2008).
[19] Author’s interview transcript 2011.
[20] López, 'Proyectan Escuela De Parteras Para Abatir Muerte Materna'. Marcela Smid et al., 'Bringing Two Worlds Together: Exploring the Integration of Traditional Midwives as Doulas in Mexican Public Hospitals', Health Care for Women International, 31/6 (2010/05/14 2010), 475-98.
[21] Professional midwife
[22] Jose Urquieta et al., 'Impact of Oportunidades on Skilled Attendance at Delivery in Rural Areas', Economic Development and Cultural Change, 57/3 (2009), 539-58.
[23] Sarah L. Barber, 'Mexico’s Conditional Cash Transfer Programme Increases Cesarean Section Rates among the Rural Poor', The European Journal of Public Health, 20/4 (August 1, 2010 2010), 383-88, Castro, Heimburger, and Ana, 'Iatrogenic Epidemic: How Health Care Professionals Contribute to the High Proportion of Cesarean Sections in Mexico'.
[24] Linda M. Hunt, Namino Melissa Glantz, and David C. Halperin, 'Childbirth Care-Seeking Behavior in Chiapas', Health Care for Women International, 23/1 (2002/01/01 2002), 98-118, Paola M. Sesia, '"Women Come Here on Their Own When They Need To": Prenatal Care, Authoritative Knowledge, and Maternal Health in Oaxaca', Medical Anthropology Quarterly, 10/2 (1996), 121-40.
[25] Mills and Davis-Floyd, 'The Casa Hospital and Professional Midwifery School: An Education and Practice Model That Works ', Smid et al., 'Bringing Two Worlds Together: Exploring the Integration of Traditional Midwives as Doulas in Mexican Public Hospitals',  (
[26] Author, 'Inecesárea: The Violence of Childbirth in Mexico', in Journal of Gender Studies (ed.), Gendered Violence Conference (Bristol UK, 2011), Author, 'Rural-Urban Migration in Chiapas, Mexico: Antenatal Violence and the Disappearing of the Midwife', Congreso Internacional Feminismo y Migración: Intervención Social y Acción Política (Barcelona, Spain, 2012), Barber, 'Mexico’s Conditional Cash Transfer Programme Increases Cesarean Section Rates among the Rural Poor',  (
[27] It is acknowledged that lack of statistical evidence does not equate to the non-existence of homebirth or midwifery in the capital city, though I have yet to come across even anecdotal evidence to the contrary. Some field data has revealed that on occasion mestiza women will travel to other locations for birthing, particularly to a nearby city where there are private birthing houses. There also a distinct lack of data in general on practices in private clinics.
[28] Generally referring to a woman who practices herbal remedies, gives massages and deals with spiritual matters, but does not officially attend births as a midwife or traditional birth attendant.
[29] Tsipy Ivry, Embodying Culture: Pregnancy in Japan and Israel (New Brunswick, N.J.: Rutgers University Press, 2010) x, 298 p. ; 23 cm.

[1] Fernando Althabe and José M. Belizán, 'Caesarean Section: The Paradox', The Lancet, 368/9546 (1472-73, Paula E. Brentlinger et al., 'Pregnancy Outcomes, Site of Delivery, and Community Schisms in Regions Affected by the Armed Conflict in Chiapas, Mexico', Social Science & Medicine, 61/5 (2005), 1001-14, Castro and Erviti, 'Violations of Reproductive Rights During Hospital Births in Mexico',  (, Marta Lamas, PolíTica Y ReproduccióN : Aborto, La Frontera Del Derecho a Decidir (1. ed. edn.; Barcelona: Plaza & Janés, 2001) 203 p. ; 23 cm, Elena Poniatowska and Mariana Yampolsky, Las Mil Y Una.. : La Herida De Paulina (1a ed. edn.; Barcelona: Plaza y Janés Editores, 2000) 160 p : ill ; 21 cm, Magaly R Sanchez, 'Insecurity and Violence as a New Power Relation in Latin America', The ANNALS of the American Academy of Political and Social Science, 606/1 (July 1, 2006 2006), 178-95, Sanchez, 'En Mexico Cada Dos Niños Hoy Nace Por Cesárea', El Universal, 18/07/2010 2010.
[2] Cited in:Barbara Rylko-Bauer, Linda M. Whiteford, and Paul Farmer, 'Global Health in Times of Violence', (1st ed. edn.; Santa Fe: School for Advanced Research Press, 2009).:7
[3] Castro, 'Commentary: Increase in Caesarean Sections May Reflect Medical Control Not Women's Choice',  (
[4] Ken Parsons, 'Testimonies of Violence', 2008 Workshop on Humiliation and Violent Conflict (Colombia University, New York:, Dec. 2008).
[5] See Arachu Castro, Angela Heimburger, and Langer Ana, 'Iatrogenic Epidemic: How Health Care Professionals Contribute to the High Proportion of Cesarean Sections in Mexico', (DAVID ROCKEFELLER CENTER FOR LATIN AMERICAN STUDIES, N.d. ), Ana Flávia Pires Lucas D'oliveira, Simone Grilo Diniz, and Lilia Blima Schraiber, 'Violence against Women in Health-Care Institutions: An Emerging Problem', The Lancet, 359/9318 (2002), 1681-85.

[1] This paper is a revised and extended version of a paper presented at the Congreso Internacional Feminismo y Migración: Intervención Social y Acción Política (FemiGra), University of Barcelona Feb 2012.
[2] Arachu Castro, 'Commentary: Increase in Caesarean Sections May Reflect Medical Control Not Women's Choice', BMJ: British Medical Journal, 319/7222 (1999), 1401-02, Roberto Castro and Joaquina Erviti, 'Violations of Reproductive Rights During Hospital Births in Mexico', Health and Human Rights, 7/1 (2003), 90-110, Arachu Castro and Merrill Singer, Unhealthy Health Policy : A Critical Anthropological Examination (Walnut Creek, Calif.: AltaMira Press, 2004) xx, 387 p. ; 24 cm, Simone G. Diniz and Alessandra S. Chacham, '"The Cut above" and "the Cut Below": The Abuse of Caesareans and Episiotomy in São Paulo, Brazil', Reproductive Health Matters, 12/23 (2004), 100-10, Tamil Kendall, 'Reproductive Rights Violations Reported by Mexican Women with Hiv', Health and Human Rights, 11/2 (2009), 77-87.
[3] Ana Maria Carrillo, 'Nacimiento Y Muerte De Una Profession: Las Parteras Tituladas En Mexico', Dynamis, 19 (1999), 170-75, Robbie DavisFloyd, 'La Partera Profesional: Articulating Identity and Cultural Space for a New Kind of Midwife in Mexico', Medical Anthropology, 20/2-3 (2001/01/01 2001), 185-243, Lisa Mills and Robbie Davis-Floyd, 'The Casa Hospital and Professional Midwifery School: An Education and Practice Model That Works ', in R Davis-Floyd et al. (eds.), Birth Models That Work (London: Univ. of California Press, 2009), Nazar a B, Salvatierra Bi, and Zapata Em, 'Atención Del Parto, Migración Rural-Urbana Y Políticas Publicas De Salud Reproductiva En Poblaciòn Indígena De Chiapas, Mexico', Ra Ximhau Revista de Sociedad Cultura y Desarrollo Sustenable,  (2007), 763-79.