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. 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.
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’. 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.
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’.
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’.
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!”
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
.
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.
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.
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.
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’.
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.
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
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 .
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.
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),
to become Skilled Birth Attendants recognised by the state or partera professional
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. 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.
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 .
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
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.
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.
