Congreso Internacional Feminismo y Migración: Intervención Social y Acción Política 9-11Feb 2012 (www.generatech.org/femigra) Rural-Urban Migration in Chiapas, Mex.: Antenatal Violence and the Disappearing of the Midwife

All content and intellectual meanderings are property of me, in as much as they can be. This work is based on ethically approved fieldwork though in an unpublished state in terms of academic peer review it is not a wise a idea to go quoting or plagiarising it... However in terms of the internet bringing forth a challenge to authoritative knowledge as it stands and the overall power struggle of validity of knowledge... do whatever you like as long as your intentions are good :) ....If you wish to use any of it send me a comment or request and I will forward my publishing alter ego for a correct reference. Femigra Conference details included below for links to all other fabulous papers and art performances that were there

J. Murray de López

Congreso Internacional Feminismo y Migración: Intervención Social y Acción Política

9-11Feb 2012 (www.generatech.org/femigra)

Rural-Urban Migration in Chiapas, Mex.: Antenatal Violence and the Disappearing of the Midwife

This paper takes as its focus the migratory experience of pregnant bodies and how, through the transient stages of reproduction, they come to embody the disappearing of cultural birth practices. It is based upon ethnographic fieldwork carried out in Chiapas in periods between 2007-2011. Throughout this presentation I will speak of embodiment in relation to the definition of anthropologist Terence Turner (1994):

• Body: as an individual psychological and sensuous response

And

• Embodiment: as a material process of social interaction
• I also use his argument of Bodiliness to help speak of the complex notion of pregnant identity and ‘a body, within a body’. I shall elaborate on concept this a little further on.

  The Rural-Urban migration of bodies for both labour and cultural reasons is highly prominent in industrialising and developing nations. In a Latin American context Mexico provides a poignant example due to its contemporary history of neoliberal policies and their direct impact on most notably rural areas and gendered labour behaviour.

The state of Chiapas is chosen strategically as a discussion point due to its social, economic and political position in Mexico. In its recent political history Chiapas has been at the forefront of grassroots and indigenous movements, the most prominent being the Zapatista Army for National Liberation, who promote widely the equal inclusion of women at all levels and a strong feminist dialectic tradition challenging global ideologies. In this vain Chiapas attracts much attention and support from activists, academics and individuals from all over the world and is often depicted as a romantic corner of Mexico where change is almost always a foot. Though as with the construction of the down trodden indigenous image, the presentation of an autonomous utopia is a creation that benefits all sides to propagate notions in contrary to the typical negatives of the post-colonial nations and also when it suits, used to reinforce them.  In this sense also the rural, migrating woman has boundaries and meanings that shift depending upon the viewpoint of the speaker and listener (Lock 1993).

In a rural context women are often represented as a conflicting presence at once down trodden and abused whilst also being resilient and strong in the face of adversity. I refer here to what anthropologist Terence Turner argues as the appropriation of bodiliness. Observing that the body in contemporary capitalist society is a site of both social inequality and personal empowerment, Turner argues that the appropriation of bodiliness is the fundamental matrix or material infrastructure of the production of personhood and social identity (Csordas 1994:18), therefore demonstrating that internal and external constructs begin from the body as well as the body being a construct of the wider social structure. The ‘body in the world’ needs to be understood as something continuous and fluctuating like a river that flows in opposite directions and occasionally crashing together in a whirlwind. If we consider this metaphor it is possible to see how contradictions of self occur and also in relation to the analysis and representation of the pregnant body as a social body.  

Whilst favour is paid to the women fighting for health and survival in rural areas, the experience of rural migrants in urban areas goes under explored. 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.  By putting some ethnographic evidence onto the bones of this discussion, we can see that this is both the cause of further violence towards women and a process

In this paper I concentrate on young women who migrate to work or study in the city and later fall pregnant and also women who migrate for reasons beyond their control such as falling pregnant out of wedlock or as a result of being raped. In short women who arrive at urban towns with few or no support networks.  In the two cities where I carried out fieldwork these women tend self-identify as being indigenous with a few exceptions.

A focus on the types of services and resources available locally for pregnant women, allows for an alternative approach to the body which is understood as (McNay terms:) “lying at the threshold of subjectivity not in terms of a fixed biological essence, nor as a result of social conditioning” (McNay 1992), rather it flows continually between.

In Chiapas pressure to improve maternal mortality rates meets with political realms of the health economy that work to oppress traditional birthing practices. Urban midwifery is not supported by statutory or non-governmental institutions and midwives practice in relative autonomy and without regulation. Women migrating to urban spaces (particularly those travelling alone) are forced into a medicalized management of their pregnancy and to submit to social service intervention in exchange for receiving any level of care. Access to healthcare is orchestrated via coercive programmes that limit antenatal care and birth to a pathologised model of pregnancy. Women who have scarce resources in urban Chiapas are left at the mercy of politically charged medical systems and at high risk of violent practices such as sterilisation without direct or informed consent, unnecessary caesarean, verbal attacks and sexual abuse . (Castro 1999: 209; Castro and Erviti 2003; Diniz and Chacham 2004; Kendall 2009) .   

Discussion: 

Together with all Mexican States that have a high indigenous population and rural geographic, in Chiapas it was estimated at the beginning of this decade that around 63% of rural births were attended at home by a traditional midwife (Hunt, Glantz et al. 2002). 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  (Hunt, Glantz et al. 2002; Smid, Campero et al. 2010). 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. Most female migrants in the urban areas of Chiapas have come from rural areas where their knowledge of childbearing will be based upon local midwifery knowledge and practices of homebirth.

In regards to the country as a whole, in urban areas a 93% of recorded live births take place in hospital (Scheper-Hughes and Lock 1987) and estimates state that 38% of all recorded live births in hospital are by caesarean section[1]. This is way above the recommended average of 15% and is a topic that has received some research attention over recent years, and was also initially the main focus of my own fieldwork. A more brutal reading of these statistics would read that the 38% of pregnant women who enter a hospital are met by a birth attendant who will cut open her abdomen and uterus, while the remaining 62% who achieve a vaginal delivery will have a deep perineum cut as part of routine episiotomy practice.

Midwifery in the urban context is an interesting cross over of indigenous and mestizo religious, cultural and lay medical knowledge practices. Spanish speaking, mestiza midwives are more often sought out for antenatal and postnatal conditions, as a complimentary attention to state medical care. This happens for various reasons though particularly in terms of financial incentive and social pressures. A pregnant woman who has migrated alone with no established social networks would have little access to a midwife practicing in the urban context.  In the capital city of Tuxtla Gutierrez midwives are practically unheard of to most women.  

Women whom I have spoke to in the urban locations of San Cristobal de Las Casas and Tuxtla Gutierrez, who had few social networks when pregnant speak of avoiding or not accessing any form of antenatal care for various reasons, the most common being:

·         Mistrust in institutions

·         Violent or Racist attitudes of medical staff on previous attempts

·         Fear of having to pay for treatment or no knowledge of welfare support due to language barriers

·         Unable to because of employment

·         Not familiar with the concept of antenatal care in a medical context

Women who did access some form antenatal check up were sent by their employer, had some familiar contact in the city or arrived at public clinics alone and were referred to a hostel connected to the clinic. Women resident in the hostel were the most likely to receive regular antenatal check ups and support post partum. Women who are employed, usually in a domestic role are back at work within days of giving birth.

I would like to conclude this brief overview by returning to my introductory notes on Turner’s notion of embodiment and my developing of his appropriation of bodiliness as a political project. The title of my paper uses admittedly strong terminology disappearing and violence – two words associated with migration discourse, though usually in terms of what happens before rather than after. I use disappearing 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 traditional 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 midwives are practising in hidden spaces and have effectively disappeared from in terms of a social presence and from reproductive health discourse.

I use violence to describe much of the maternal care that women are subjected to in public institutions.  Having little or no record of antenatal care and no family support can leave a woman vulnerable to unnecessary surgical intervention and associated abuses when she arrives at the hospital in labour.

Of the women I have met and birth attendants interviewed throughout my fieldwork I have found that those women entering one specific Regional Maternity Hospital for a first full term pregnancy, not only overwhelmingly had a birth outcome of C-Section after reportedly having had a healthy pregnancy, but also I find a regular practice of what is termed a classical incision – a vertical cut through the abdomen to reach the uterus, which is then cut horizontally. In WHO guidelines and medical publications the classical incision is described as something that should only ever be practised in cases where there are literally minutes to intervene before mother or baby die, or other strong clinical evidence. It is a practice rarely used in industrialised nations.

The scar left behind after such an intervention holds multiple complication for the woman – in physical, economic and symbolic terms- this scar comes to represent violence and represents on the whole societal attitudes to women of specific social and ethnic categories. The physical and economic effects from the wound restrict a woman’s movement, ability to earn money and chances of future pregnancies. Symbolic effects I shall touch upon in my finishing sentences:

 Pregnant Embodiment: as a material process of social interaction demonstrates the State’s role in the production of personhood and social identity of pregnant women, who in this case are also migrants. The 3 inch scar from belly button to pubic bone seals the process and marks the woman’s body as a site that represents the continuing death of cultural woman centred birth practices. 

References:

Castro, A. (1999). "Commentary: Increase in Caesarean Sections May Reflect Medical Control Not Women's Choice." BMJ: British Medical Journal 319(7222): 1401-1402.

               

Castro, R. and J. Erviti (2003). "Violations of Reproductive Rights during Hospital Births in Mexico." Health and Human Rights 7(1): 90-110.

               

Csordas, T. J. (1994). Embodiment and experience : the existential ground of culture and self. Cambridge, Cambridge University Press.

               

Diniz, S. G. and A. S. Chacham (2004). ""The Cut above" and "The Cut below": The Abuse of Caesareans and Episiotomy in São Paulo, Brazil." Reproductive Health Matters 12(23): 100-110.

               

Hunt, L. M., N. M. Glantz, et al. (2002). "CHILDBIRTH CARE-SEEKING BEHAVIOR IN CHIAPAS." Health Care for Women International 23(1): 98-118.

               

Kendall, T. (2009). "REPRODUCTIVE RIGHTS VIOLATIONS REPORTED BY MEXICAN WOMEN WITH HIV." Health and Human Rights 11(2): 77-87.

               

Lock, M. (1993). Encounters with aging: mythologies of menopause in Japan and North America. Berkeley; London, University of California Press.

               

McNay, L. (1992). Foucault and feminism : power, gender and self. Cambridge, Polity.

               

Scheper-Hughes, N. and M. M. Lock (1987). "The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology." Medical Anthropology Quarterly 1(1): 6-41.

               

Smid, M., L. Campero, et al. (2010). "Bringing Two Worlds Together: Exploring the Integration of Traditional Midwives as Doulas in Mexican Public Hospitals." Health Care for Women International 31(6): 475-498.

               

Turner, T. (1994). Bodies and anit-bodies: flesh and fetish in contemporary social theory. Embodiment and Experience: the existential ground of culture and self. T. J. Csordas. Cambridge, Cambridge University Press.

               

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[1] In Mexico estimation is required to correct for under-reporting of c-section deliveries in private facilities 

La Dignidad Rebelde?

"For many in Mexico today the world seems, indeed to have gone mad. It is a world where politicians funnel eighty four million dollars from the national coffers into Swiss bank accounts, where protesters sew their mouths closed with black nylon string in politically motivated hunger strikes, where students take to the streets in angry riots, and where policemen slaughter dozens of campesinos and hide their bodies in shallow graves. Divorces and homicides are up, literacy rates and education down, and so many young people seem more engaged with what's happening in Friends than in their own back yards"

R. Lester, 2005

   Since the early 1980’s a slow, yet steady rebellion has been taking place throughout Los Altos of Chiapas, the body count of indigenous women, children and men as a result of supporting this rebellion or just being in the wrong place at the wrong time has crossed into 4 figures. Political prisoners are into the hundreds and Chiapas remains a militarized state away from the media gaze. Just like the recent public uprising and rioting in various countries, the Zapatista movement only made the world press when they appeared armed and used violence  (whether symbolic or physical) to get their message across. Since they put down their arms to continue in a non-violent struggle in the face of an uber-violent State one has to search them out to find them in terms of media coverage.

Chiapas remains within the top 5 most marginalized states of Mexico, alongside neighbouring Oaxaca it has a high indigenous population, is rich in natural resources and has an inconceivably huge class and racial divide resulting in a burgeoning middle class who appear apathetic to the abject poverty and starvation that surrounds them. 

My experience of this place over eight years has taught me that an imagined vision (and language) of a 1^st and 3^rd world (who ever got to be the 2^nd??), is nothing but a constructed concept. Break these concepts down and what do they mean any way? Perhaps just another label imposed by powerful governments to say “you are down there, and there you will stay”?... after all has anyone heard of a country that gets relegated to 3^rd or upgraded to 1^st?

What does poverty mean when you have no running water or electricity but you have a mobile phone and cable tv??

The force known to many as neoliberalism no longer has a distinct definition, not one that can be easily fitted into a sentence and applied willy nilly to any situation. It is better to think of neoliberalism as a phantom that haunts society and nation at every level. It is a creature that changes, morphs and reinvents so quickly that its hard to know where it will turn up next. Neoliberalism seeps into every aspect of if social and individual life. It is easy to look at the large scale political and economic actions that are rooted in the free market philosophy of survival of the fittest. The decrease of state funded services, universal benefits and praise of privatisation as the best option are apparent to even the most ignorant of shopping channel souls.  The commodification of everything from body parts to feelings – from those breasts that will make you a winner, the designer foetus that grows into a flawless success, to the happiness that can be bought in any shopping centre or online paradise – now that’s a little harder to pin down.

It’s the emotional and cognitive effect on the individual that is intrinsically linked to the collective social world, and vice versa which can only be tackled through theoretical analysis. Perhaps that is why the effects of neoliberal/free market/neo-capitalist forces on the emotional human being defy an understanding in the common world. If you can’t get hold of something, pin it down, give it a name, catch the phantom at work – how does it become part of the general consciousness?

We blame our unhappiness on whatever our media devices tell us is causing it. The strongest will survive, free market mentality tells us that unhappiness is caused by not having enough – it doesn’t matter what of, you just don’t have enough of it. This translates into the individual a feeling of never quite getting there, never being satisfied and always wanting better. Those who commodify the phenomena of health will tell us that this is depression, a chemical imbalance and that there’s a pill that can fix it and a good therapy or holistic religion for those that can afford it. Your diagnosis can then be traded to earn particular benefits and acceptance in the world you live in. 

Pedagogic theorist Peter Mclaren writes that our feelings are attached to the shimmering surface effects of signs and simulations, and the dull radiance that illuminates the spectacles of everyday. In other words, our feelings have been made external in order that we may recognise them only as emotions accepted by a particular society, at a particular time. This separation between internal and external feelings leads to social confusion. When there only exists a language to explain the socially constructed external emotions we receive on a superficial level, our profound internal emotions are alien to us, we have no way to explain them to ourselves and therefore no understanding of how we should react. As social and emotional beings we do react, and do so in an automatic sense, in ways that seem irrational and violent precisely because there is no other way to understand action that has no constructed meaning. We have lost all ability to recognise our internal repulsion and coping mechanisms to the world around us.

Whether it is Mexico, Egypt, Spain or the UK the world seems to be a mad place for no one dominant reason in particular. Perhaps the phantom neoliberal effect on the individual via the fetishism of commodification has reached its limits of subtlety, and the world is finally waking up to the madness it has caused. No longer can a shimmering surface effect explain away the levels of inequality and injustice that exist in the one world we all live in.

Childbirth in Urban Chiapas (without footnotes)

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

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

Chiapas, Reproductive Health and (Mis)Development

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

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

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

The focus on Caesarean Section in Urban Chiapas

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

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

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

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

Medic v’s Midwife

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

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

Conclusion: Women, Pain and Modernity

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