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: http://researchingsecurity.wordpress.com/our-publications/conference-papers/what-can-anthropologists-offer-to-security-studies/ 

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. 

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.), (http://www.cemece.salud.gob.mx/descargas/pdf/BIMMyM5.pdf 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', 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).

[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: http://www.humiliationstudies.org/publications/publications.php, 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 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.

Parir con dolor: La violencia obstétrica en los servicios de salud

Parir con dolor: La violencia obstétrica en los servicios de salud

I'm reposting this article as it connects directly to my previous post and highlights very well that YES Obstetric Violence does exist in ethnographic terms - i.e. a local understanding and acceptance of the issue as experienced and felt by women.

Publico esta articulo de la Jornada porque conecta muy bien con el ultimo post - que si existe la violencia obstetrica y esta entendido asi por las mujeres que sobreviven la experiencia de intervenciones innecesarias:

• La postura de la secretaría de salud es que aun cuando puedan causarse daños a la salud de las mujeres por impericia o negligencia, ya existen vías civiles y penales para castigarlos
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  • ilustración: NotieSe

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  México DF. Cuatro de cada diez nacimientos en México se realizan por cesáreas, muchos de ellos, sin requerirlo. La presión psicológica a la que son sometidas las mujeres en labor de parto para que acepten practicársela por parte del personal de salud ha generado una discusión a nivel mundial.
  
  Por un lado, los médicos defienden la modernidad de los procedimientos quirúrgicos relacionados con el nacimiento, y por otro, organizaciones civiles trabajan para fomentar un modelo de atención que favorezca la salud de la mujer y proteja la relación cercana entre ésta y su recién nacido.
  
  "Me hicieron cesárea, pero yo creo que hubiera nacido normal. Las enfermeras me gritaban mucho, me decían que iban a aprovechar para operarme porque ya tenía muchos hijos. En medio de los dolores me hicieron firmar un papel que no entendí. Toda la noche me metieron la mano. Sufrí mucho el parto". Cuatro de cada 10 nacimientos en México son a través de cesáreas, un porcentaje que rebasa las recomendaciones internacionales. Apenas un indicador, quizá el más evidente, de una serie de prácticas negativas que siguen realizándose cotidianamente en las instituciones públicas y privadas de salud: la violencia obstétrica que sufren miles de mujeres, forzadas a parir con dolor.
  
  Calificar como violencia el maltrato médico durante el embarazo y el parto es motivo de debate internacional, y ha conducido a definiciones legales e, incluso, a su tipificación como delito. Se puede entender por "violencia obstétrica" el trato deshumanizador, el abuso de la medicalización y la patologización de los procesos naturales del parto que trae consigo la pérdida de autonomía y de la capacidad de decisión de parte de las mujeres durante su embarazo y parto. Este tipo de abusos van de lo psicológico (la socorrida frase propinada a muchas doloridas parturientas: "¡aguántate!, hace nueve meses no te dolía, ¿verdad?") a lo físico, como las esterilizaciones forzadas.
  
  En México, Veracruz ha sido pionero en identificar el problema y ha incluido la figura de violencia obstétrica dentro de su Código Penal; Chiapas también ha integrado el término a su marco legal. En Oaxaca, una iniciativa de reforma sobre el tema está atorada en el Congreso; la comunidad médica local, con el secretario de salud a la cabeza, la repudia y presiona para que sea desechada.
  
  

  El parto es natural 
  Hace más de cuatro décadas el médico francés Michel Odent planteó, frente a una cada vez mayor medicalización del nacimiento, lo que luego se conocería como "parto humanizado", una serie de técnicas vistas en su época por la medicina institucional como extravagantes, o incluso peligrosas, pero que poco a poco han mostrado beneficios en la salud de la mujer y el recién nacido. Sutilezas como retrasar unos minutos el corte del cordón umbilical o favorecer la inmediata proximidad entre madre e hijo, o recomendaciones revolucionarias, como el parto en posición vertical. Hoy, la Organización Mundial de la Salud (OMS) insta a "reducir el uso excesivo de tecnología o la aplicación de tecnología sofisticada o compleja cuando procedimientos más simples pueden ser suficientes o aún superiores".
  
  En México, la Guía de Práctica Clínica para la vigilancia y manejo del parto, del Consejo de Salubridad General (formada por instituciones públicas de salud y asociaciones de médicos), integra algunas de estas recomendaciones básicas, como permitir que la mujer pueda moverse libremente previo al trabajo de parto, favorecer la posición semi sentada para la expulsión, o limitar prácticas comunes como la amniotomía (la ruptura artificial de la "fuente" para inducir el parto), la episiotomía (incisión en la zona perineal para ampliar el canal para el parto) o la administración de oxitocina (hormona artificial que acelera el parto, aunque también puede hacerlo más doloroso).
  
  La Secretaría de Salud (Ssa) contempla proyectos para ampliar la capacidad de acción de las clínicas de atención básica y para que el eterno sobrecupo de los hospitales deje de fomentar negligencias y violencia obstétrica. El doctor Hernán García Ramírez, de la Dirección General de Planeación y Desarrollo en Salud de la Ssa, habla de un proyecto novedoso: abrir "posadas de nacimiento" que aligeren la carga de los centros de segundo y tercer nivel. "Las posadas de nacimiento estarían cerca o al lado de los hospitales, donde la mujer puede llegar antes, hospedarse, y si su parto es normal, atenderse ahí mismo, sin necesidad de médicos, atendida por enfermeras obstétricas o parteras. Te ahorras infraestructura, pues no requieren el gasto que requiere la atención hospitalaria", explica García Ramírez.
  
  Planes aparte, la realidad se impone: según la Comisión Nacional de Arbitraje Médico, la gineco-obstetricia fue la tercera de las disciplinas que más quejas de pacientes acumuló en 2011. Y el porcentaje de cesáreas realizadas entre 2000 y 2010 en el país fue de los más altos del mundo: 37 por ciento; la recomendación de la OMS indica no superar las 15 por cada 100.

  
  

  La resistencia al cambio 
  "En esa institución [en la que hacía mi primer año de residencia] se registraba un índice de cesáreas altísimo, 70 por ciento sólo durante el turno de la tarde. Se buscaba cualquier pretexto para indicar cesáreas y así practicar a costa de las pacientes. Además, se utilizaba una cantidad de oxitocina excesiva, provocando que muchos partos terminaran en extirpación del útero. Esto para ellos no hablaba de fracaso. Al contrario, era algo positivo porque les permitía practicar las histerectomías obstétricas". El testimonio es de una médica residente en un hospital del área metropolitana de la ciudad de México, recopilado en un artículo publicado en la revista Género y Salud (Ssa, septiembre-diciembre de 2010).
  
  En los últimos años ha habido una tendencia internacional a legislar sobre la violencia contra las mujeres. "La Convención sobre la eliminación de todas las formas de discriminación contra la mujer, de las Naciones Unidas, obliga a los Estados a legislar de manera específica, porque las cosas que le pasan a las mujeres no les pasan igual a los hombres, por ejemplo, los feminicidios: el tipo penal de homicidio no alcanza para comprender todo lo que pasa cuando una mujer es asesinada", comenta Mayela García, activista de Veracruz que participó de cerca en la tipificación del delito de violencia obstétrica en ese estado.
  
  En 2007, Venezuela se convirtió en el primer país en definir legalmente la violencia obstétrica y en tipificarla como delito; dos años después el caso de una mujer que perdió a sus gemelos por negligencia fue conocido en todo ese país y se convirtió en el primer caso procesado a través de esta ley.
  
  En 2010, el Congreso de Veracruz inició discusiones para incluir la violencia obstétrica en la Ley de Acceso de las Mujeres a una Vida Libre de Violencia, además de tipificarla como delito en el Código Penal. Tras siete meses de debate la reforma se aprobó por unanimidad. "Cuando se aprobó, comenzamos a capacitar a las y los prestadores de servicios de salud, a capacitar a las mujeres en la exigencia del respeto a sus derechos, a formar y profesionalizar a los ministerios públicos", cuenta Mayela García, que también es consejera del Instituto de las Mujeres de Veracruz.
  
  El gremio médico, primero en Veracruz, ahora en Oaxaca, se opone a que se legisle sobre el tema. Uno de los argumentos es que se criminalizaría la práctica médica. "Reconocemos que tenemos que mejorar la calidad en la atención de las mujeres, pero no cometemos actos con dolo, no podemos estar a la par que los violadores. Definitivamente estamos en contra", dice la médica Maritza Hernández Cuevas, presidenta del Colegio Oaxaqueño de Ginecología y Obstetricia.
  
  Para Emilio Álvarez Icaza, activista y ex director de la Comisión de Derechos Humanos del DF, los opositores a estas reformas buscan preservar un "modelo médico-céntrico" que tiene intereses de poder —80 por ciento de la actividad médica en el sector público se centra en la atención de partos— e incluso económicos, sobre todo ligados a la práctica de cesáreas: ante la constante saturación del sector público, estas intervenciones son realizadas en hospitales privados con cargo al erario. "Sé que la cesárea es una opción, sin duda, pero lo que la estadística reporta es que México vive un abuso", comentó luego de participar, en marzo pasado, en un foro organizado por el Congreso oaxaqueño para discutir la propuesta.
  
  Según datos de la organización civil Consorcio para el Diálogo Parlamentario y la Equidad, cada cesárea le cuesta al sector salud 23 mil pesos. y tan sólo en 2011 se registraron 12,435 en Oaxaca, de acuerdo a cifras de la Secretaría de Salud.

  
  

  Disputas en Oaxaca 
  Oaxaca fue la entidad pionera en la que se practicaron los nacimientos humanizados en los hospitales públicos. Entre 2009 y 2011, funcionó un área específica de partos con estas características en el Hospital Civil Aurelio Valdivieso, el más importante de la capital oaxaqueña. A eso se suma la revalorización de la partería tradicional, que atiende a un porcentaje alto de mujeres indígenas al interior del estado. Sin embargo, la sanción a la violencia obstétrica está atorada.
  
  En agosto de 2011 el gobernador de Oaxaca, Gabino Cué, envío al Congreso local un paquete de reformas a la Ley Estatal de Acceso de las Mujeres a una Vida Libre de Violencia de Género y a los códigos penales que, entre otras cosas, incluye la tipificación de la violencia obstétrica. En vísperas del 25 de noviembre, Día Internacional de la Eliminación de la Violencia contra las Mujeres, se anunció su aprobación, pero sin el apartado obstétrico. La movilización de activistas impidió el madruguete, pero dejó en el aire toda la reforma.
  
  La oposición fundamental viene de los médicos, paradójicamente liderados por el secretario de salud estatal, Germán Tenorio Vasconcelos, él mismo dueño de una clínica particular en la capital del estado, quien ha declarado que "la ley no debe entrar en la relación médico-paciente".
  
  De acuerdo con la organización civil Nueve Lunas, una de las principales impulsoras del tema de violencia obstétrica, la oposición de Germán Tenorio bloqueó la negociación que estaba en marcha con la Comisión Estatal de Arbitraje Médico de Oaxaca, para aclarar los alcances que tendría la penalización de la violencia obstétrica como última opción en casos graves, como las esterilizaciones forzadas, y para abrir nuevos cauces civiles para otros casos de abusos médicos. "Pararon todo y difundieron, a través del sindicato de Salud, que cualquier médico o enfermera que participara en una cesárea podía ir a la cárcel, lo cual es una mentira y una manipulación", aseguran en Nueve Lunas.
  
  La postura de la secretaría de salud estatal, según explica su director jurídico, Octavio Holder Cruz, es que aun cuando puedan causarse daños a la salud de las mujeres por impericia o negligencia, ya existen vías civiles y penales para castigarlos. "Debemos tener mucha precaución en no legislar sobre lo que ya se encuentra legislado", asegura.
  
  Para el médico Félix Quintero, coordinador del módulo de parto humanizado en el Hospital Civil —el cual se encuentra cerrado de momento— su gremio sólo busca protegerse en un entorno donde la infraestructura y el equipo son insuficientes para garantizar una atención médica de calidad, pero reconoce que también hay resistencia a cambiar. "La cultura en la atención obstétrica está muy arraigada, el cambio de paradigmas es complicado", considera.
  
  Por lo pronto, el líder sindical Jenoé Ruiz López ha amenazado con paralizar todas las actividades en los servicios estatales de salud en caso de que la reforma prospere. Y no hay una fecha para que los diputados locales retomen la discusión.

  
  

  ¿Qué es el nacimiento humanizado? 
  La Organización Mundial de la Salud recomienda varias prácticas en la atención del parto:

  Permitir a las mujeres que tomen decisiones acerca de su cuidado.

  Un miembro elegido de su familia debe tener libre acceso durante el parto y todo el periodo postnatal.

  El equipo sanitario también debe prestar apoyo emocional.

  Libertad de movimiento y posición durante el trabajo de parto y parto.

  No hacer episiotomía de rutina.

  No hacer rasurado y enema de rutina.

  No hacer monitoreo fetal electrónico de rutina.

  Permitir toma de líquidos y alimentos en trabajo de parto.

  Restringir el uso de oxitocina, analgesia y anestesia.

  Limitar la tasa de cesárea al 10-15%.

  Poder decidir sobre la vestimenta (la suya y la del bebé), comida, destino de la placenta y otras prácticas culturalmente importantes.

  En México, el porcentaje de cesáreas es de 37 por ciento, el octavo más alto del mundo.

  En el sector público, una cesárea cuesta 23,000 pesos.

  En Oaxaca se practicaron 12 mil 435 cesáreas durante 2011.

• Tags Relacionados: Parto, dolor, obstetricia, salud publica, atencion medica, salud reproductiva
• Fuente: Letra S-La Jornada

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