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.
 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.
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).
 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.), (http://www.cemece.salud.gob.mx/descargas/pdf/BIMMyM5.pdf 2009).
 Brentlinger et al., 'Pregnancy Outcomes, Site of Delivery, and Community Schisms in Regions Affected by the Armed Conflict in Chiapas, Mexico', (
 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.
 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).
 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).
 D'oliveira, Diniz, and Schraiber, 'Violence against Women in Health-Care Institutions: An Emerging Problem', (:1681
 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', (
 From author’s field notes August 2011.
 In most public hospitals only the woman and medical staff are allowed in the delivery suite.
 Castro and Erviti, 'Violations of Reproductive Rights During Hospital Births in Mexico', (
 Estimation is required to correct for under-reporting of c-section deliveries in private facilities.
 Who, 'Estadísticas Sanitarias Mundiales', in Who (ed.), (World Health Organisation, 2011).
 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.
 Fernando Althabe and José M. Belizán, 'Caesarean Section: The Paradox', ibid.368/9546 (1472-73.
 Citlali López, 'Proyectan Escuela De Parteras Para Abatir Muerte Materna', http://www.noticiasnet.mx/portal/principal/90850-proyectan-escuela-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).
 Author’s interview transcript 2011.
 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.
 Professional midwife
 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.
 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'.
 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.
 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', (
 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', (
 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.
 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.
 Tsipy Ivry, Embodying Culture: Pregnancy in Japan and Israel (New Brunswick, N.J.: Rutgers University Press, 2010) x, 298 p. ; 23 cm.
 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.
 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
 Castro, 'Commentary: Increase in Caesarean Sections May Reflect Medical Control Not Women's Choice', (
 Ken Parsons, 'Testimonies of Violence', 2008 Workshop on Humiliation and Violent Conflict (Colombia University, New York: http://www.humiliationstudies.org/publications/publications.php, Dec. 2008).
 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.
 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.
 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.
 Ana Maria Carrillo, 'Nacimiento Y Muerte De Una Profession: Las Parteras Tituladas En Mexico', Dynamis, 19 (1999), 170-75, Robbie Davis‐Floyd, '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.