letter from chiapas

Monday, 12 March 2012

A Review of Ethnography Literature concerned with Medical Education and Obstetrics

Working on context and history the following review attempts to discuss what's there and what's missing - in order that I may find a place for myself in the vast space of Anthropology of Pregnancy...
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‘Now for the sense of ‘context’. Most generally it is a name for a whole cluster of events that recur together – including the required conditions as well as whatever we may pick out as cause and effect.’ (Richards 1936)

This review of ethnographic and theoretical literature relating to the learning of obstetrics and medicine begins with a discussion of context, or more specifically a theory of contexts. I refer here to the practice of Articulation (Grossberg 1992) – where the construction of one set of relations comes out of another. Ethnography of pregnancy in Chiapas should be revealed as montage, interrelating contexts that result from social theory and cultural practice rubbing against one another (as proposed by Taussig 1992). Wanting to find out about the actual experience of pregnant women must include a focus on the knowledge, power and practices that inhabit their world. ‘Articulations are never simple and singular; they cannot be extracted out of the interlocking context in which they are possible’ (Grossberg 1992). In this way I wish to take account of obstetrical medicine as cultural practice, as it is reflected onto a specific society via the pregnant body. It will become clear from my review of ethnography centred around medical education that medicine as an all-encompassing cultural practice outside of a UK/US context, is an aspect that has been somewhat neglected.

Grossberg advocates that to understand a practice one must historically and theoretically (re)-construct it context (1992). In doing so such (re)-constructing should inevitably lead to the processes of learning (Lave and Wenger 1991). For this reason I have also included literature that analyses the historical construction of medicine and anatomy, without which a present day context would not exist. In the course of unpicking existing ethnography of medical learning (or any kind of learning to be in the world) one is instantly presented with multilayered dispositions. Evans (2006) explains these dispositions as an embodied understanding of a particular way of being amongst others. Relating her analysis of social learning and violence to the work of Lave and Wenger (1991) and their theory of legitimate peripheral participation Evans argues for the recognition of emotion in the learning process. In doing so she highlights the importance of the varying and tacit things that contribute to the practice of learning. Echoing Lave and Wenger’s sentiment that learning is a cultural context that is best analysed outside of an institutional context Evans’ discussion in this paper is useful for beginning to think about learning as socially constructed practices.

A substantial amount of ethnographic work exists in regards to traditional midwifery practice and apprenticeship in Mexico (see Jordan 1993; Sesia 1996; Davis‐Floyd 2001; Tinoco-Ojanguren, Glantz et al. 2008; Mills and Davis-Floyd 2009; Smid, Campero et al. 2010). The learning experience and development of the medical profession in Mexico has come under little scrutiny in existing ethnography. An anthropological approach to medical education should focus on the cultural conditions of practices, what is being learnt and then how this translates into practice. The medical student understood as apprentice in a specific community of learning provides an appropriate space for this to happen. The year of social service that a Mexican student must complete at the end of their degree – where they are often sent to rural or heavily oversubscribed urban clinics demonstrates the ultimate passage of apprenticeship and presents the opportunity of an ethnographic understanding of interrelation between medical/traditional practices [1].

Historical Analysis and ethnography of Medical learning

‘...the body is simultaneously a physical and symbolic artefact,..both naturally and culturally produced, and...securely anchored in a particular historical moment...[Yet] we take scientific discourse about human biology to be not simply a narrative but a universal truth...we assume that it applies anywhere at any time and transcends time and place’ (Lock 1993)

In medical terms the specific historical anchor of the body that Lock is referring to can be found in the development of anatomical dissection and pathology – the emergence of the medical gaze. The anatomical approach was based on the assumption that the more one knew of structure, the better one understood of function (Sinclair 1997:44). By stripping away the layers of the human body its different functions were exposed and translated into fact by prominent physicians of that time. Social and historical analysis of anatomy practices as knowledge creation tends to be based in the Foucauldian assertion that: ‘The gaze plunges into the space that it has given itself the task of traversing...In anatomo-clinical experience, the medical eye must see the illness spread before it...it is the body itself that has become ill’ (2003:166-167). This anatomo-clinical experience of the medical gaze is a crucial historical juncture that denotes a shift in relationship between physician and patient, ownership of illness and diagnosis becomes that of the physician. From what they are able to see and feel, which must conform to what already exists in text, the physician is now expert of the body that is somehow detached from the subjectivity of the patient.

Anatomical theatre, University of Leiden 1596 online source: Wikipedia

The practice in anatomical theatres (16^th and 17^th Century), for apprentice physicians was one of observation, of master refereeing from text to body (as opposed to creating text from the body present). The transmission of personally acquired experience to publicly available knowledge is further challenged via the classical artistic style of the period that depicted the dissected body parts and the events themselves (excellent analysis of anatomical art history can be found in: Martin 1989; Sinclair 1997; Massey 2005). Depictions of dissected bodies as artist impressions served to transmit tacit knowledge as concrete medical fact as soon as it appeared in print. This is particularly poignant in regards to the historical construction of the female body, reproductive organs and the pathologizing of pregnancy and birth. During the eighteenth century the publication of two highly regarded obstetric atlases contributed substantially to the epistemological reformulation of childbirth as a medical rather than domestic concern. ‘Stark, brutal and fetishistically naturalistic, these eighteen-century obstetric images medicalized and pathologized childbirth in an unprecedented way (Massey 2005). By pathologizing pregnancy and birth the female body was not only affirmed as a passive recipient of diagnosis, the pregnant body took on s similar representation to ill bodies in need of regulating and treatment. The peculiar aesthetic of the medical gaze– ‘the practitioner’s ability to describe the body persuasively and elegantly, in infinitesimal detail from the inside out’ (Massey 2005) - culminated in a medical recognition of the foetus as a life product, an entity completely separate from the mother.

Jan van Rymsdyk's most famous plate from William Hunter's "Anatomy of the Human Gravid Uterus".

A significant aspect of the anatomical approach is the loss of lay meanings for words used in a medical context (Martin 1989; Sinclair 1997; Martin 1999; Kitzinger 2006), and also how under the medical gaze ‘unambiguous words apply unambiguously to unambiguous things’ (Sinclair 1997). What Sinclair means by this is that things are given a name and then measured as normal or abnormal according to that name. In The Woman in the Body: A Cultural Analysis of Reproduction, Martin (1989) analyses at length the terminology for the female body’s varying life cycle processes such as ‘degenerate’, ‘weakened’, ‘withdrawn’ and ‘lack’. This sentiment in regards to the use of eponyms and body function adjectives is echoed by Kitzinger in her discussion of obstetric language: ‘Gynaecologist’s names are attached to parts of women’s bodies and processes of reproduction as if these men had invented them; Fallopian tubes, Bartholin’s glands...If the baby does not engage...it may be because [the woman] has an ‘inadequate’ pelvis. When the cervix is slow to dilate, it is...’incompetent’...’ (2006:22). This use of language then becomes a way of seeing the world, how students come to categorise bodies in their social world.

When presenting their theory of situated learning Lave and Wenger state that participation ‘is always based on situated negotiation and re-negotiation of meaning in the world’ (1991). The process of transformation that a student will experience involves applying such ‘unambiguous’ terms in everyday life and practices, therefore also demonstrating a shift in how those students will begin to see all aspects of their lives through the medical gaze. The anatomical model forms the basis of medical education and alongside this the pathology model– the body as ill, the machine as broken. The primary stages of medical learning involve ‘scientising the self’ and the world around you (Sinclair 1997), the eponyms used in anatomy and pathology medicine reinforce the notion that this scientific basis itself is a masculine episteme – or as Sinclair so directly states in his ethnography, that: ‘Medicine is a man’s world’ (1997:143).

Understanding the development of biomedical discourse through the detailed writing of thinkers such as Foucault or Martin is an essential starting point for the study of medicine and medical learning. This is however, one aspect of a study and is in no terms complete if one wishes to make sense of cultural context and local practices. Ethnographic study must go beyond what Good and Good (1993) argue to be the portrayal of a monolithic “biomedicine” that is treated itself as a conceptual category. In their preliminary analysis of the learning experiences of preclinical medicine at Harvard University, they remind us of the dangers of the diametrically opposing views in much medical anthropology between “biomedicine” and “traditional healing”. They point out that this is not helpful in anthropological analysis and culminate in a view of traditional medicine as untouched by biomedicine and vice versa. At its extreme, the use of biomedicine as a conceptual category fails to take into account the agency and interpretations of the people being studied and does not deal with the different types of medical discourses at play in an educational institution.

In depth ethnographic studies of the medical student as apprentice learner, in the educational setting are limited and have come under criticism for paying minimal attention to the external influences, personal meanings and the phenomenology of ‘specialized medical worlds’ (Good and Good 1993; Sinclair 1997; Atkinson and Pugsley 2005).

The most prominent examples of medical education ethnographies are: Merton and Kendell (eds) The Student Physician (1957); Becker et al’ Boys in White (1961); Bloom’s Power and Dissent in the Medical School (1973); and Sinclair’s Making Doctors: an institutional apprenticeship (1997). Although not an exhaustive list, it is clear from these titles that there is a long tradition of ethnographic research in medical education in a UK and US context. Whilst they vary in focus from institutional mechanisms (Merton and Kendall 1957; Bloom 1973); professional socialisation (Merton and Kendall 1957; Becker 1961; Sinclair 1997) and power and authoritative knowledge (Bloom 1973; Good and Good 1993; Sinclair 1997), none pay particular attention to the interlinking social contexts and the influence of outer society inside the medical school or vice versa. ‘To say that a practice is defined by its effects is to locate the practice in its connections to its exterior, to that which is other to it’ (Grossberg 1992:53 my emphasis). Instead, ethnographies set in medical education environments have tended to isolate the students and the learning activity from the political, economic and social contexts of the outside world. Sinclair does present the argument that previous ethnographies have failed to deal with the influence of medical specialities that they have ‘been passed over in favour of the assumed homogeneity of the teaching institution’ (1997:14), his work does make a decent attempt to break away from this. Sinclair’s ethnography is still limited in some respects due to its use of the biomedical model as a conceptual category somehow frozen in historical context. Preliminary work by Good and Good is by far the most useful text for considering ‘...the phenomenological dimensions of medical knowledge, on how the medical world, including the objects of the medical gaze...are reconstituted in the process...’ (1993:83) of learning to be a doctor.

Anthropological and sociological literature on medicine and reproductive health in Mexico evidences that medical curriculum and clinical authoritative knowledge have their roots in European and North American practices. Ethnography of midwifery models and practices identifies the use and influences of biomedicine (Jordan 1993; Davis‐Floyd 2001), though the opposite has not occurred in any study of medical or obstetric practice outside of a historical analysis. This instead tends to fall into the trap already discussed of the untroubled monolith “biomedicine” and/or medical “discourse”, untainted by personal meanings or the world of disease and suffering (Good and Good 1993).

Existing medical education ethnography is useful for the general theoretical arguments it presents towards cultivating a professional identity and exclusive community of practice. However a deeper understanding of the organisational structure of the Latin American medical school; how authoritative knowledge is culturally absorbed and changed; the more complex interlinking contexts of gender, class and ethnicity; and professional/social status of obstetrics is needed in order to understand its role in pregnancy and childbirth in a local context.

“Iatronic Epidemic” and its links to Authorative knowledge in contemporary cultural education systems

Links between authoritative knowledge, political economy and relations to the State are well documented themes in medical anthropology and also anthropology of pregnancy (Ginsburg and Rapp 1995; Szurek 1997; Ivry 2010) and further connection needs to be made to the role of State (in local and global contexts)and how this informs educational curriculum and the things that medical students learn. This is an argument that Bloom (1989) puts forward in his paper on the sources of resistance to change in medical schools. By analysing the evolution of organisational structure of medical school in varying countries and regions he demonstrates how medical education is inextricably linked to the health service system. Bloom provides a useful model of the Latin American medical school which he generalises as:

‘autonomous professional school connected to the central administration of the university but with no connection to other parts of the university, combined with open admission immediately after secondary school and student activism’ (Bloom 1989).

Though not entirely unproblematic in its generalisation (particularly between the public/private institutions), this is a useful definition when thinking about the position of the medical school as straddling the general university space, elite professional status space and with the university hospitals, a direct connection to the public health service in action. Medical learning does not happen in a vacuum away from cultural practice and society and one could assume that the curriculum must reflect the direct practices of the hospital or clinic – which in turn are driven by health and welfare initiatives of that given time. The nature of apprentice learning will also mean that students are learning from physicians who continue to practice, moving between an idealised text book static medicine and a multi-layered, everyday practice of medicine defined by cultural, political and economic contexts.

The iatronic epidemic is a term used by Castro (2003; 2004; 2004; N.d. ) who has examined violations of reproductive rights in Mexican hospitals including practices of unnecessary caesarean sections, transcaesarean contraception insertion and sterilization without direct consent. By comparing ethnographic data with existing statistical data from the mid 1990s through to 2001, Castro et al (N.d. ) describe how obstetricians can be the driving force behind the rapid rise in caesarean sections, to a point where Mexico is now amongst the highest incidences in the world (Althabe and Belizán ; WHO 2009; Castro, Heimburger et al. N.d. ). An iatrogenic epidemic refers to a practise in relation to its effects, a problem caused by doctors by their own actions. In this case that of gyno-obstetricians in Mexican hospitals (public and private) and interventions in pregnancy and birth. Grossberg establishes that: ‘...a practise is not where it is...but at all of those sites where its existence makes a difference to the world’ (1992:53). Here there is a direct connection to Castro’s work and the theoretical basis’ of learning discussed in the introduction to this literature review. By providing further links to teaching hospitals and cultures of surgical intervention in the learning of obstetrics, Grossberg’s practice of articulation provides a tool for analysing the interlocking cause and effect from educational institution to wider societal context, from community practices to individual lives.

The work of Castro in Mexico City public hospitals is the closet one becomes in trying to relate obstetrical education knowledge and practice in a Mexican context, and also in relation to political economic realms of health policy. There is a need to re-address some of the major issues brought out by Castro’s detailed ethnographic work, in respect that the context of pregnancy in Chiapas can never a stable subject of study. Since Castro’s data was collected Mexico has changed its President and majority party twice; there has been a global financial crisis; Millennium Development Goals have entered into their final phase; and baseline welfare provision has further developed (Seguro Popular and Oportunidades cash transfer programme) leading to clinical provision in more rural areas and with that further meshing of urban and rural medical practice. How medical and obstetric education has evolved alongside these political and economic stages and the links to economic crisis, structural violence and reproduction have yet to come under any ethnographic analysis.

In essence there is a good existing base of ethnographic literature from which to build upon. Ethnography of reproductive health and pregnancy in Mexico also tends to reflect that of the wider literature – much analysis begins with the practice of qualified and experienced gyno-obstetricians. Where students and educational structure appear they tend to do so as a background concern. This may be because they are often in an observing, apprentice role and so are described for participation around the main character – the seasoned obstetrician or consultant. In doing so ethnographic understanding of learning medicine and obstetrics is so far absent from the focus on institutional practices – in so much that it could be accused of being taken as a given, as if the training of medical students is a dormant part of the wider context. This is in direct comparison to celebrated ethnographic studies of Mexican midwifery in terms of apprentice learning and meanings of professional that use learning practices as their very focus. I refer here again to Grossberg’s proposition that a practice located in its connections to its exterior and the interrelated effects it has on that exterior, is what opens up the practice and makes it visible to social analysis. In this respect ethnographic analysis of pregnancy and birth in Chiapas must take into account the learning of obstetrics and institutional identity as part of the wider context.

References

Althabe, F. and J. M. Belizán "Caesarean section: the paradox." The Lancet 368(9546): 1472-1473.

Atkinson, P. and L. Pugsley (2005). "Making sense of ethnography and medical education." Medical Education 39(2): 228-234.

Becker, H. S. (1961). Boys in white : student culture in medical school. Chicago, University of Chicago Press.

Bloom, S. W. (1973). Power and dissent in the medical school. New York;London, Free Press ;Collier Macmillan.

Bloom, S. W. (1989). "The medical school as a social organization: the sources of resistance to change†." Medical Education 23(3): 228-241.

Castro, A. (2004). Contracepting at Childbirth: The intergration of reproductive health and popultation policies in Mexico. Unhealthy Health Policy: A Critical Anthropological Examination. A. Castro and S. Merrill. Plymouth Altamira.

Castro, A., A. Heimburger, et al. (N.d. ). Iatrogenic Epidemic: How Health Care Professionals contribute to the High Proportion of Cesarean Sections in Mexico, DAVID ROCKEFELLER CENTER FOR LATIN AMERICAN STUDIES.

Castro, A. and M. Singer (2004). Unhealthy health policy : a critical anthropological examination. Walnut Creek, Calif., AltaMira Press.

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

Davis‐Floyd, R. (2001). "La partera profesional: Articulating identity and cultural space for a new kind of midwife in Mexico." Medical Anthropology 20(2-3): 185-243.

EVANS, G. (2006). "Learning, violence and the social structure of value." Social Anthropology 14(02): 247-259.

Foucault, M. (2003). The birth of the clinic. London, Routledge.

Ginsburg, F. D. and R. Rapp (1995). Conceiving the new world order : global politics of reproduction. Berkeley, London, University of California Press.

Good, B. and M. Good (1993). Learning Medicine: The Constructing of Medical Knowledge at Harvard Medical School. Knowledge, Power and Practice: The Anthropology of Medicine and Everyday Life. S. Lindenbaum and M. Lock. London, Univ. of California.

Grossberg, L. (1992). We gotta get out of this place : popular conservatism and postmodern culture. New York ;

London, Routledge.

Ivry, T. (2010). Embodying culture: pregnancy in Japan and Israel. New Brunswick, N.J., Rutgers University Press.

Jordan, B. (1993). Birth in four cultures : a crosscultural investigation of childbirth in Yucatan, Holland, Sweden, and the United States. Prospect Heights, Ill., Waveland Press.

Kitzinger, S. (2006). Birth crisis. London ;New York, Routledge.

Lave, J. and E. Wenger (1991). Situated learning : legitimate peripheral participation. Cambridge, Cambridge University Press.

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

Martin, E. (1989). The woman in the body : a cultural analysis of reproduction. Milton Keynes, Open University Press.

Martin, E. (1999). "The Egg and the Sperm: How Science has Constructed a Romance Based on Stereotypical Male-Female Roles." Signs: Journal of Women and Culture Vol. 16 no. 31: 485-501.

Massey, L. (2005). "Pregnancy and Pathology: Picturing Childbirth in Eighteenth-Century Obstetric Atlases." The Art Bulletin 87(1): 73-91.

Merton, R. K. and P. L. Kendall (1957). The student-physician : introductory studies in the sociology of medical education. Cambridge, Mass., Published for the Commonwealth Fund by Harvard University Press.

Mills, L. and R. Davis-Floyd (2009). The CASA Hospital and Professional Midwifery School: An education and Practice Model That Works Birth Models that Work R. Davis-Floyd, L. Barclay, B. Daviss and J. Tritten. London, Univ. of California Press.

Richards, I. A. (1936). The philosophy of rhetoric. New York ;

London, Oxford University Press.

Sesia, P. M. (1996). ""Women Come Here on Their Own When They Need to": Prenatal Care, Authoritative Knowledge, and Maternal Health in Oaxaca." Medical Anthropology Quarterly 10(2): 121-140.

Sinclair, S. (1997). Making doctors : an institutional apprenticeship. Oxford, Berg.

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.

Szurek, J. (1997). Resistance to Technology Enhanced Childbirth in Tuscany: The Political Economy of Italian Birth. Childbirth and Authorative Knowledge Cross-Cultural Perspectives. London, Univ. California Press: 287-314.

Taussig, M. T. (1992). The nervous system. New York, London, Routledge.

Tinoco-Ojanguren, R., N. M. Glantz, et al. (2008). "Risk screening, emergency care, and lay concepts of complications during pregnancy in Chiapas, Mexico." Social Science & Medicine 66(5): 1057-1069.

WHO (2009). Rising caesarean deliveries in Latin America: how best to monitor rates and risks, World Health Organsiation.

[1] There have been some pilot programmes of incorporating local midwifery in clinical spaces for example see: 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.

Thursday, 16 February 2012

Debaten diputados proliferación de cesáreas - Can legislating EVER do any good??

Photo borrowed from: http://www.theunnecesarean.com

La Jornada: Debaten diputados proliferación de cesáreas

Well what can I say? - ¿Qué puedo decir?

And no-one is asking WHY???Yet another political game and argument washing over what is really an important and violent fact: Mexico has a 38% caesarean rate, as mentioned in this article surgery has become the most used method of birthing humans in the country.

In translation I will explain that this newspaper article is discussing an amendment to the General Health Act in the Mexican parliament. There is a proposal to reform article 62 of the Act to make it state that caesarean sections should only be performed if there is a justifiable medical cause.

Valiant an effort it may be to finally begin to recognise that there is a significant problem and over use of c-section, which at least opens up debate in the public arena. Predictably enough two parties (PRD and PAN) strongly associated with the church and supporting neoliberal structural readjustment to federal and state public services are against this proposal. In Mexican politics I find it difficult to differentiate between the PRD and PRI in terms of their actions – as politicians swap party alliances more often than a Latin American gets arrested in the States- We may as well just throw the 3^rd main party in the mix as well!

The opposing politicians (the majority male and so losing my attention from the start because as with the abortion/reproductive rights debate – they have no real place in this debate a their bodies will never be in that place) – are playing the human rights card on this one. Stating that it is against a woman’s right to decide over her body – that essentially a woman should be able to choose how she gives birth.

Here we have the first major problem: The Rhetoric of Rights

This whole thing about CHOICE is super dodgy yet difficult to argue against – it’s like when those irritating sales people halt you by saying “You mean you don’t want to save money on your gas bill?”

As you hear yourself replying “no”, you do this and cringe a little because this question in its essence is rhetorical – a question that is not meant to be answered because in this case socially speaking the answer is obvious.

The same principle applies to human RIGHTS questions – can you really argue against phrases such as – “A woman has a right to decide over her own body” which is why phrases such as this are so easy to throw into any political argument no matter whose side you’re on. The same goes for the whole CHOICE semantic juggling...

Whilst now throwing this argument into the midst – when debating the legalisation of abortion PAN politicians are not wishing a woman to have the right to decide over her body – not even if she has been raped! In this case they are calling for the RIGhT To LIFE – whatever that may mean?

THIS is a problem of turning something like rights and choice into a thing that can be legislated for or against – turned into a THING for the statute books – which essentially is a thing that is decided upon and controlled by the State not the community or individual.

In Mexican history there exists a change from what is known as Human Rights as natural to Human Rights as a statute which can be legislated and interpreted as Universal. Anthropologist Shannon Speed discusses this in great length in her 2007 ethnography on the indigenous struggle and Human Rights in Chiapas (Rights to Rebellion). Specifically how amendments made to the Mexican Constitution in the moment that NAFTA and neoliberal structural readjustment were forced upon Mexican citizens made a general shift was made in human rights discourse as something than can be negotiated and individualised.

In 1994, the same year that the North American Free Trade Agreement was introduced (popular opposition to which greatly enhanced public discourse on rights to land, resources and discrimination of indigenous peoples), on a global stage the International Conference on Population and Development (in Cairo) began an important terminology shift from population control to one of rights to reproductive health. International discourses of reproduction since Cairo have tended to be framed in terms of individual rights (Morgan and Roberts 2009) and freedoms, this has also been reflected in national Mexican health policy and NGO work since. This rhetoric of individual rights and freedoms is based on a notion of universalism, and so unlike ideas of ethnicity, gender, religion, education, social inequalities and attitudes, health and environmental problems, human rights discourse transcends culture and political context. Universal rights have a fixity that means they can be set into international law and embody a regulatory force open to interpretation. The concept of human rights is inseparable from the nation state as both defender from and instigator of violence via state institutions (see R. Wilson 1997 ).

The most frightening quote in this article is from a PAN politician Laura Elena Estrada who arguing against the amendment also added that the families who accompany women should be able to decide on a C-SECTION birth in the woman’s BEST INTERESTS. This is something I have come across in my own research as women have told me that abusive partners or other relatives have signed papers agreeing to surgery (c-section and/or tubal ligation) when the labouring woman has refused. WHERE IS THE WOMAN’S RIGHT TO CHOOSE OVER HER OWN BODY HERE???

If we leave it in the hands of the politicians to decide how we birth – will it ever end well?

Sunday, 12 February 2012

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.

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.

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