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Emma BD épisiotomie

L’épisiotomie fait la Une : Retour sur la semaine où ma veille s’est emballée

[Article publié le 31 juillet 2017, mis à jour le 7 Août 2017]

“Alors comme ça on déconnecte un peu et on se réveille avec #épisiotomie faisant les gros titres des journaux ?!” La surprise de Doulavocate sur Twitter résume bien le séisme qui a secoué le monde de la naissance la semaine dernière, suite à l’évocation dans l’enceinte du Sénat, des violences obstétricales. Pour celles et ceux qui auraient pris des vacances, je vous propose de faire le point sur cette surprenante semaine en trois actes.

Doulavocate on twitter

[Les sources de cet article proviennent de mes alertes Google et feeds twitter et Facebook, qui n’a pas vocation à être exhaustif. N’hésitez pas à me signaler tout article paru depuis le 20 juillet et que je n’aurais pas cité dans la partie commentaires, avec la date de parution et le lien.]

Prologue

L’apparition sur la scène politico-médiatique des violences obstétricales est le fruit de plusieurs années de travail par différent.e.s acteur.rice.s, comme le CIANE (Collectif InterAssociatif autour de la Naissance), les réseaux sociaux (groupe Faceboook Stop à l’Impunité des Violences Obstétricales (Sivo), hashtag #PayeTonUtérus sur Twitter), le blog de Marie-Hélène Lahaye (Marie accouche là), le groupe Gyn & Co et de journalistes. D’ailleurs, le 17 juillet, soit quelques jours avant les déclarations de la Secrétaire d’Etat chargée de l’Egalité entre les Femmes et les Hommes, l’émission Le Débat de Midi sur France Inter portait sur la maltraitance médicale (avec Marie-Hélène Lahaye, Odile Buisson et Dominique Dupagne). L’attitude d’Odile Buisson lors de ce débat illustre deux tendances que l’on retrouve dans les articles ci-dessous, soit la remise en cause de la parole des femmes et le renversement de situation, en focalisant le débat sur la maltraitance envers les soigant.e.s. Pour deux critiques élaborées du débat, je renvoie vers les posts de Marie-Hélène Lahaye et Martin Winckler.

Acte I : l’audition de Marlène Schiappa et la commande au HCE-fh

Tout commence le Jeudi 20 juillet. Lors de son audition par la Délégation Droits des Femmes au Sénat, Marlène Schiappa évoque les violences que vivent certaines femmes lors de leur accouchement et annonce qu’elle a commandé un rapport au Haut Conseil à l’Egalité entre les femmes et les hommes (HCE-fh) sur le sujet (à 9min50 de la vidéo). Elle mentionne 75% d’épisiotomies, mais n’explicite pas qu’elle se réfère-là à une enquête menée par son association, Maman Travaille, auprès de près de 1000 femmes. Comme on peut le constater sur mon graphique, l’annonce n’est pas immédiatement suivie d’un emballement médiatique (j’ai classé cette annonce dans communiqué de presse (CP), pour faciliter la lecture).

Donc au final, tout commence vraiment le Lundi 24 juillet, suite au communiqué de presse publié sur le site du Secrétariat. Une polémique naît notamment grâce à la réponse quasi immédiate et pleine de bienveillance du Conseil National des Gynécologues et Obstétricien.ne.s es (CNGOF), communiqué qui est repris par une dépêche AFP. Vous pouvez lire le communiqué du CNGOF en entier ici (spoiler: pas de remise en cause des pratiques). Dans la soirée, Le Monde publie le premier article sur la guerre des chiffres, soit le faux désaccord sur le nombre de périnées coupés.

Acte II: la controverse des chiffres

Le 25 juillet, on le voit sur le graphique, c’est l’explosion médiatique. C’est le jour où le plus de papiers sont publiés. La plupart des articles sont explicatifs, définissant ce que sont les violences obstétricales et/ou l’épisiotomie (FranceTv infoRMC) et abordant souvent la question de la fréquence des épisios (Libération ;20 minutes ; Le Monde/ Les Décodeurs ; LCI).

Le même jour, l’interview d’Israël Nisand sur BFM nous montre qu’on est loin d’une remise en question de la relation soignant.e.s – soigné.e.s, tandis que France Bleu en profite pour nous rappeler qu’à la maternité de Besançon, le taux d’épisiotomie est de 1% (oui, c’est possible).Sur FranceInter Israël Nisand frappe encore en qualifiant Marlène Schiappa de “populiste”. Dans son communiqué de presse, l’Institut de Recherche et d’Action pour la Santé des Femmes (IRASF) se réjouit quant à lui de la commande du rapport au HCE-fh.

Peu d’articles datés du 25 juillet donnent la parole aux femmes, sûrement en raison du temps pour récolter les témoignages. Le seul qui apparaît est celui de FranceTv Info, publié en 2016 et actualisé ce jour-là. Pour l‘Express et sur son blog, Marie-Hélène Lahaye explique l’importance que revêt l’emploi de ce terme au niveau politique. Un article du lendemain de Femme Actuelle reprend aussi des témoignages de femmes publiés plus tôt dans l’année dans la presse et sur Facebook (Paye ton Gynéco et le Sivo).

Le 26 juillet, on continue avec les débats autour des chiffres (Public Sénat). Israël Nisand, qui avait décliné l’invitation à débattre sur France Inter le 17 juillet (cf début de cet article), accepte celle de RMC, pour (surprise) continuer à ne pas écouter les femmes. Ce même jour le SYNGOF publie un communiqué de presse appelant à la démission de Marlène Schiappa. De son côté, Atlantico publie une interview d’Odile Buisson qui juge que les violences obstétricales sont un “phénomène exagéré”. A contrepied, deux interview, celle de Martin Winckler dans Ouest France (qui propose de voir l’épisiotomie comme une mutilation sexuelle) et celle de Clara de Bort dans Marianne (qui rappelle que les personnes à utérus ont aussi des cerveaux) viennent apporter un débat de fond sur le traitement des femmes et de leurs corps. Consoglobe se réjouit de la “levée d’un tabou”, et inclut dans son article la vidéo de Draw My News qui explique en dessins ce qu’est l’épisiotomie.

Acte III: la parole aux femmes

Le 27 juillet, dans son communiqués de presse, le Conseil National de l’Ordre des Sages-Femmes (CNOSF) se félicite du rapport commandé par la Secrétaire d’Etat. En revanche, sur France Inter, l’invitée de 7h50 Ghada Hatem tient la ligne du discours CNGOF en ne remettant pas en cause ses pratiques et déconsidérant l’expérience des près de 750 femmes interrogées par Maman Travaille qui ont subi une épisiotomie. Dans l’Humanité,  Marie-Hélène Lahaye s’interroge quant à elle sur l’impact aux violences obstétricales sur la vie des femmes, notamment en termes de stress post-traumatique.

C’est à partir de ce jour que les paroles des femmes prennent plus d’ampleur dans les medias. Slate se pose la question du consentement et Cheek Magazine nous conseille fortement la lecture de l’article de FranceTv Info susmentionné (25 juillet).

Le 28 juillet, le communiqué de presse du CIANE conclut que les bourdes sur les chiffres peuvent être utiles en politique. Un article de RTL Girls explicite les différentes formes de violences, à l’aide de témoignages. Les témoignages de femmes sur la violence obstétricale (Ouest France) croisées d’interview de médecins (Clara de Bort pour Marianne ; Nesrine Callet également pour Marianne), mettent en lumière les expériences  douloureuses des femmes pendant leur accouchement. A cette occasion, la BD d’Emma sur l’épisiotomie de son amie Cécile (parue en 2016) resurgit via une interview sur LCI (j’en profite pour la remercier de m’avoir autorisée à utiliser une des planches pour illustrer ce post).

La semaine continue et le 29 juillet, RTL Girls fait le point sur la polémique un article en Anglais dans the Times aborde la polémiques des chiffres de l’épisiotomie, mais surtout pour s’en prendre à la Secrétaire d’Etat sur d’autres sujets. Et sur la page Facebook de la maternité de Nanterre, Benoît de Sarcus se retranche derrière un discours sur le risque, lui qui dans l’article de FranceTV Info du 25 juillet dénonçait la pratique de l’épisiotomie.

Pour clore cette semaine incroyable, le 30 juillet le Journal du Dimanche publie une tribune de Marie-Hélène Lahaye, en face de celle du SYNGOF. Les divergences sont toujours là, tant il semble impensable que les femmes puissent exercer un contrôle sur leur propre corps. La bataille de pouvoir autour du sexe des femmes continue, espérons que le futur rapport du HCE-fh permettra, au-delà des chiffres, d’amener un débat de fond sur les pratiques en salles de naissance.

graphique épisiotimie media France 21 juillet 06 août
L’épisiotomie dans les medias du 20 juillet au 06 août

Acte IV: le tweet de la relance

Une nouvelle semaine, une nouvelle polémique (même si l’emballement médiatique est moins important, comme on peut le voir sur le graphique). Le 1er août, Marie-Hélène Lahaye (oui, toujours) publie sur Twitter la photo d’un extrait du livre les Paresseuses, partagée dans le groupe Facebook SIVO. L’extrait en question explique aux femmes enceintes que durant leur accouchement leur “intimité va se transformer en hall de gare”, les conditionnant ainsi à subir des violences. Ce tweet est partagé plus de 800 fois. LCI publie immédiatement un papier. L’information est reprise le lendemain par le Huffpost, BFMtv et Femme Actuelle.

Cette polémique relance le débat sur les violences obstétricales, et le 2 août le Nouvel Obs publie une interview avec Sarah Lahouari, co-fondatrice de Paye ton Gynéco sous le titre “Il faut arrêter l’omerta”. Le même jour sur le site de Neon Mag Didier Riethmuller répète que l’épisiotomie ne devrait pas être automatique, tout en rêvant d’une France qui serait le modèle à suivre en termes de pratiques gynécologiques (spoiler: on n’y est pas encore).

Le 3 août, pour la première fois les violences obstétricales sont évoquées sur une chaîne d’information; BFMtv partage le témoignage d’une mère et une interview de Mélanie Dechalotte. Pour les militantes, c’est un moment historique. Il reste cependant du chemin à faire puisque le lendemain, 4 août, Capital pose la question de la maltraitance gynécologique, mais y répond en Oui/Non/Peut-être, ce qui revient à remettre en cause la parole des femmes.

Je termine sur un appel à témoignages pour Le Monde. Si vous souhaitez partager votre histoire, c’est PAR ICI.  [On signale un dysfonctionnement sur la plateforme, n’hésitez pas à écrire au Monde sur Facebook ou Twitter si c’était le cas].

Épilogue: internationalisation des débats

Le débat autour de l’épisiotomie et des violences obstétricales a résonné au-delà des frontières françaises. Le 29 juillet, soit dès la première semaine où le sujet est fortement médiatisé en France, la question s’invite en Belgique. Le Soir publie une interview de Marie-Hélène Lahaye et Fabienne Richard (directrice du Groupe pour l’Abolition des Mutilations Sexuelles) sur l’épisiotomie. Le même jour, DH.be publie des témoignages de violences obstétricales (d’ailleurs le titre est quasi identique à l’article de France Info “quand l’accouchement vire au cauchemar”). Le 31 juillet c’est le journal néerlandophone De Morgen qui publie aussi un article sur le sujet.

Enfin le 6 août Yabiladi.net se demande ce qu’il en est au Maroc, où la pratique semble également banalisée. Dommage que la sage-femme interviewée s’intéresse plus aux risques d’une épisiotomie mal faite/recousue plutôt que d’interroger la pratique en elle-même.

Espérons que le débat continue, et permette de recueillir des statistiques en France, en Belgique et au Maroc, et à interroger encore et toujours la nécessité de l’épisiotomie et à dénoncer les actes non consentis.

Ostrach book cover

Book Review: Ostrach’s 2017 Health Policy in a Time of Crisis

[Review Originally published on Anthropology-News ]

In Catalunya and beyond, abortion is never just a medical or even a moral issue. It is an explosive nexus of intense social conflict over power, ‘rights,’ bodily autonomy, access to health care and the equal distribution of resources in society” (Ostrach 2017: 69).

Ostrach 2017

Health Policy in a Time of Crisis stems from ten months of institution-based participatory research in a healthcare clinic—Public Clinic—providing state-funded abortion services in Barcelona. Using a mixed-method approach, Ostrach surveyed 350 women who sought abortion care at the Public Clinic, interviewed 11 women on their experiences with the public health system in seeking abortion as well as 11 providers on their perspectives of the experiences of the hundreds of women for whom they provided abortion care.

This methodologically grounded and theoretically innovative ethnography is informed by the author’s long-standing engagement with the topic of abortion rights and access in the United States. In a context of global restrictions on women’s reproductive rights and the fight of activists worldwide for legal access to abortion, the author vividly demonstrates how legal abortion does not necessarily equate with abortion access. Health Policy in a Time of Crisis takes abortion as a window to analyze the everyday impact of austerity measures (national and European) and shifting status for immigrants on abortion access. The shadow of La Crisis, the widespread recession that struck most of Europe from 2007 on, and the consequent austerity measures, forms the background of women’s decisions to get abortion care, health personnel’s struggle to provide it, and the Public Clinic’s ability to maintain full access to all women seeking its services. Austerity cuts during the author’s fieldwork translated in a drastic reduction of the number of publicly funded abortions, illustrated by women who had come for a procedure in previous years’ saying, “better a crowded clinic than no clinic!”

Contrary to much of Latin America, where some countries have the strictest abortion laws of the planet, there is little stigma associated with abortion in Barcelona, and even women who personally oppose abortion strongly contest legislative attempts to put restrictions on women’s bodies. Ostrach builds on feminist critique to analyze the notion of “bodily autonomy,” which is central to Catalan activists’ demand for abortion access for all. The emphasis on bodily autonomy challenges mainstream discourses on reproductive rights. Catalan activists’ grassroots demands for access to reproductive care and bodily autonomy rather than the right to abortion echoes many demands of activists and indigenous peoples across Latin America, who frame access as rights in practice, rather than theoretical human rights.

In Catalunya, demands for bodily autonomy are interwoven with protests for regional autonomy, and a strong commitment to healthcare access for all, no matter their residency status. In this peculiar context, one might think that barriers to access are reduced. However, Ostrach’s research showed that 51 percent of the 350 women surveyed were not aware that their abortion would be fully state-funded, even as they had interacted with at least one health system representative. Building on Harvey’s civilized oppression framework, Ostrach vibrantly reveals how the power imbalance between women seeking information about abortion services, with some healthcare workers abusing their authority, shape women’s access to health services. In particular, immigrant women were most likely to report being misinformed on the gestational limit for abortion, encountering delays in seeking abortion services, and being provided with the incorrect referral voucher, for example. In some cases, structurally marginalized women faced ongoing stereotypes and had to convince providers that they were worthy of public funds.

Health Policy in a Time of Crisis is an empathic ethnography on women’s frustrations, as they face a wide-range of obstacles such as terminating a wanted pregnancy because of La Crisis, the lack of access to transportation to the only publicly-funded clinic in the region, or finding a companion to wait for them after the procedure, as required by the clinic protocol. The women Ostrach interviewed were particularly insightful on the multiple challenges they had to face in addition to seeking abortion care—as single mothers, sex workers, and students. The author eloquently describes these efforts in the “Superwoman complex”: the strategies deployed by women to balance fewer economic resources and less perceived support for their abortions. Ostrach’s vivid descriptions of women’s journeys, and the long quotes of women themselves bring las dones (the women) to life, as they share their frustrations with the health system and these personal and structural obstacles.

Immigrant women in particular (from South America, other parts of Spain, and other European countries) encountered more delays in accessing abortion and arrived on average two weeks later than Catalans at the clinic. Factors accounting for this delay included women’s lack of awareness that the procedure would be covered upfront, and the shifting status of immigrants, which led to misinformation about their health coverage. Ostrach eloquently describes how providers’ attitudes can shape women’s access, and how some stereotypes shape the staff interactions with certain groups of patients like Roma or Muslim women, but the impact it might have on women’s experiences and their willingness to access the service is left unanswered. The author acknowledges the limitation of her study on immigrant women’s experiences, as she focused on those women who accessed the clinic, and raises important questions for future research, such as, what happens to immigrant women who are completely unaware of the public healthcare coverage for pregnant women? And, what are the stories of those who encountered too many delays and were unable to get the procedure?

To conclude, this exceptionally well-written and engaging ethnography is a constant reminder that “abortion is nothing without access,” at a period of revival of conservative movements in Europe—making the news in France and Poland recently—and increased restriction on abortion access in the United States. Health Policy in a Time of Crisis provides a unique example of engagement in medical anthropology. Ostrach shared the results of her investigation on the concrete impacts of funding cuts for the public clinic with representatives of the public health system. Even though the meeting did not result in a change in policy, such engagement symbolizes important calls for action. This promising first book will speak to a wide audience, offering insights for discussions in research methods and ethics classes from all disciplines, and the fields of medical and applied anthropology, women and gender studies, and public health and migration studies, to name a few.

Book Reviewed: Ostrach, Bayla. 2017. Health Policy in a Time of Crisis: Abortion, Austerity and Access. New York and London: Routledge.

Long-Distance Ethnography

A tool for collaboration between anthropologists and NGOs

Since 1985, the Organization of Indigenous Doctors of Chiapas (OMIECH) has been supporting and promoting the work of traditional midwives in indigenous communities in the Highlands of Chiapas. Collaborating with non-governmental organizations, anthropologists and medical doctors in Chiapas as well as abroad, OMIECH has built an international and intercultural network to raise awareness about the disappearance of traditional midwifery. Since 2010, the Women and Midwives Section of OMIECH has partnered with the French NGO Association Mâ, an organization promoting natural and respected childbirth in France.

I met members of OMIECH in 2013 through the Association Mâ, as I was starting my doctoral studies. We began collaborating as an aspect of my doctoral fieldwork. My research questions stemmed from preliminary fieldwork with OMIECH, and my dissertation, documenting the impact public health policies on indigenous midwives’ work, is informed in part by narratives of midwives who belong to the OMIECH network. As my fieldwork developed, I volunteered for both Mâ and OMIECH, on-site during my fieldwork, and at a distance through communication platforms such as Skype the rest of the time. In this essay, I reflect on our collaboration by presenting my activist researcher position, and the tools we have used to make this collaboration sustainable.

Activist Anthropology

In many ways, activist research is a lesson in humility, as we adapt our methods of research to meet our collaborators’ needs.

You know, a lot of researchers have come here. We gave them all the information, we talked to them, and then, they never came back,” Micaela Icó Bautista, the coordinator of the Women and Midwives Section of OMIECH told me during the weeks following our first encounter. In addition to never seeing the researchers again, her and her colleagues were upset that they were never acknowledged in the research nor received a copy of any publications about them. The Women and Midwives’ Section shared with me the work of students who interned with them as well as journal and newspaper articles about the organization that they were able to gather over the years. However, according to Micaela and her colleagues, more researchers have come to work with them who never shared their results. In this context, we spent our very first meeting, during which I presented my research interests to OMIECH, discussing common grounds between the organization’s goal and my academic skills.
In many ways, activist research is a lesson in humility, as we adapt our methods of research to meet our collaborators’ needs. As a result of my long-distance collaboration with OMIECH’s Women and Midwives’ Section, I have come in contact with midwives across the globe, and learned to balance between “doing” (being involved in projects) and “writing” (about such projects). In such, my commitment to OMIECH’s political goal taught me to revisit my writing to make it relevant to my partners, as well as writing for advocacy.

Anthropologists working in the field of human rights take on the multiple roles of witnesses, advocates and activists. Ultimately, activist-research relies on the belief that political engagement is in continuity with our anthropological training, what Shannon Speed calls doing “critically engaged activist research” (2006). The activist side of my research also positioned me as an outsider within, providing a vantage point to auto-analyze my own interactions within OMIECH and note the differences in opinion and experience that might arise between my colleagues and myself. Simultaneously approaching OMIECH as a doctoral student and as a member of their French partner organization has placed me in uncomfortable situations at times, but allowed me to fully live participant-observation, and gain the kind of knowledge that allows me to talk about the politics of indigenous organizing “from the gut” (Bernard 2006; 342).

SLACA2015
Micaela Icó Bautista, Mounia El Kotni, and Alice Bafoin at the 2015 SLACA meeting in Oaxaca.

Techniques and Technologies: Making it Work

In total, I completed thirteen months of on-site fieldwork in Chiapas, spread over a period lasting from May 2013 to July 2015.  Despite our various geographical locations, OMIECH and I have been able to write projects together, present our work in academic settings such as the 2015 SLACA conference, and organize local events in France and Chiapas.

The use of technology is crucial to conduct this type of ethnography and to collect data without being physically in the field, what I refer to as long-distance ethnography. Maintaining regular contact with OMIECH while in the United States has been essential for my research and even more crucial in developing trust. I conducted long-distance ethnography over a period of four months in 2014 which included the video recording of bi-monthly meetings of the Women and Midwives’ Section, and my response to these recordings through email and/or video messages. In face-to-face participant-observation, the presence of the researcher is slowly erased through a process of habituation and trust building. In a similar way, in long-distance ethnography, the webcam, at first odd, became integrated into the meetings. By the second recorded meeting, I had questions directed towards me/the camera.

Results

The possibilities of activist research are multiplied by the availability of new technologies (videoconferences, file sharing, Internet-based calls). In our case, they have contributed to building a dialogue with such diverse publics as academics, activists, parteras and families in Chiapas, France and the USA. As anthropologists, long-distance ethnography also challenges our research methods, which often limit our “doing” to the field, while the “writing” happens at home. On both OMIECH and my side, technology has contributed to good working relationships between us, allowing both my colleagues to update me with important news from the organization, and me to keep them updated about my dissertation work. Video platforms, instant messaging, and social media all shorten the spatial and mental distance between fieldwork and home. By allowing our research partners to interfere in our daily routine, they create new ethical questions, and make us accountable beyond the occasional phone call. Ethical and methodological questions about long-distance ethnography also make their way in the training of future anthropologists, who, wherever their fieldwork takes them, will rely on their use.

Chiapas health workers strike against reforms

[Article originally published in ROAR Magazine]

Workers of the Chiapas Health Jurisdiction have been on strike for one month, in protest against the structural reforms the government intends to pass.

It isis 8:30 pm and the nurses are just starting their 12-hour shift. “There are three teams. Now we have a 12-hour shift, until 8 am tomorrow morning, and then we come back 24 hours later,” one of them explains. Workers from different health institutions of the city of San Cristóbal de las Casas have organized the distribution of supplies in the tents blocking the road to the Woman´s Hospital and the Health Jurisdiction. During the long shifts, “some bring coffee, some bring food, and others come with hunger,” says another nurse, laughing.

DSC03331
Nurses on strike

Workers of the Health Jurisdiction of Highlands Chiapas, which is comprised of workers from 18 municipalities have been on strike for over one month, in protest against the eleven structural reforms the government has been trying to pass. In particular, they explain that the so-called “universalization of healthcare” which would merge the different public healthcare institutions of the country would have disastrous consequences in Chiapas, one of Mexico’s poorest states.

The current universal healthcare (Seguro Popular) covers about 300 procedures. The previous program covered over 3,000. “And with this reform, there will be barely a hundred procedures covered, leaving out chronic illness such as diabetes and acute conditions like cancer,” a union representative explains. And in a country with vast income disparities, universal healthcare’s unique cost for uncovered procedures would not be accessible to poor peasants living in the states of Oaxaca (where the police repression led to 12 dead, a hundred wounded and 25 disappeared in Nochixtlan a few weeks ago),Guerrero (where 43 students were disappeared in September 2014) and Chiapas. The biggest health costs will thus be shouldered by patients themselves, and not by the state.

The privatization of healthcare is in line with international reforms promoted by lending agencies, such as the World Bank and the Inter-American Development Bank, and will benefit those already in the business of health, like the Mexican telecom magnate Carlos Slim. “This is a model that does not fit with the reality of Mexico, and what we as workers are starting to implement are local consultations with lawyers, researchers, and activists to find a new health model” decries another union leader at a press conference on June 30. Protesters are also calling out to the state’s lack of knowledge and interest in the operating conditions of the health institutions. “In the hospitals here, we lack medicine and even machines. Sometimes there are not even syringes. The only thing doctors can do is fill out prescriptions and send patients to buy out-of-pocket medications in pharmacies”. In the face of such shortages, staff members often help out their poorest patients by paying the costs out of their own pocket.

IMG_2123
Sign of protest outside of the Health Jurisdiction.

The discontent with the law is plenty: “For those of us who will be retiring, we would only be getting 1,080 pesos a month (about 60 USD)” explains one healthcare worker. “Our colleagues working in laboratories will be judged on their productivity, not on the number of hours; in order to comply with their goals they will have to either work more hours or increase the number of patients per hour,” describes another.

Even though the Highlands’ Jurisdiction is the only union on strike in the state so far, health workers from all over the country marched in protest on June 22. In Chiapas, teachers, families, students and residents of different districts of the city have shown solidarity with the movement: “Night after night, people from the barrios bring us coffee and show their support.”

Twenty-two days after declaring a “Permanent Assembly,” the 2,500 workers stand firm. So far, the health reform has been paused, “but this does not mean that it will not be reactivated,” cautions the union representative, “we will not dismantle our Permanent Assembly.” The health workers say they have learned a lot from the teachers, who have been mobilizing against radical changes in the education system as well. “We are barely learning how to walk. But we will walk together with the teachers and peasants.”

Reforming Pregnancy Care and Childbirth in Chiapas

[Article originally published as part of the Childbirth in the Americas series on Anthropology-News]

At each consult with a pregnant woman, Doña Gabriela starts by asking: “Does your head hurt? Do you hear buzzing in your ears? Do you feel nauseous? Have you vomited? Do you see little lights?” After more than fifteen years of monthly trainings at a local clinic, these questions have become part of Doña Gabriela’s routine. Doña Gabriela knows that if the woman answers yes to one of these questions, called señales de alarma (alarm signals), it means that she (a midwife) might not be allowed to attend the woman’s birth:

If the woman has all of these [signals], then we won’t be seeing the birth, it is better if she goes with the doctor. This way, we come out clean. This is what we learn. (…) [When we get to the hospital] we just hand the woman over and that’s it. They don’t allow us in. We hand her over in the emergency room, that’s it. Before, they allowed us in, but now they don’t anymore. (Doña Gabriela, June 2015, interview with Jaime de las Heras)

State policies aiming to train indigenous midwives (parteras) gradually reshape their role in the health care system; indigenous parteras shift from being independent health care providers to becoming health auxiliaries — what I call alarm signal detectors.

El Kotni_Pic1

Poster describing the alarm signals during pregnancy posted at Public Hospital, San Cristóbal de las Casas, February 2015. Photo courtesy Mounia El Kotni

Diminishing maternal deaths

Since the World Health Organization’s launch of the Safe Motherhood Initiative (SMI) in 1987, international efforts have focused on training Traditional Birth Attendants in hygiene (boiling instruments, washing hands) and encouraging them to refer women to hospitals. In this framework, pregnancy and childbirth are perceived as risky processes; with every pregnant woman potentially at risk of having a complication (Nicole Berry discusses the impact of the SMI and other international programs on Guatemalan women and midwives.) In Mexico, the combined effect of the International Conference on Primary Health Care (Alma Alta, 1978) which targeted “health for all, by 2000” and the SMI accelerated the construction of health centers in rural communities. Rural parteras trained in hygiene and the detection of alarm signals for referral to the hospital. Yet these one-size-fit-all recommendations, encouraged by international organizations such as the World Health Organization (WHO) and United Nations Population Fund, fail to take into account the realities of women in Chiapas.

Located in southeastern Mexico, the State of Chiapas has one of the highest rates of maternal and infant deaths of the country: 54.8 for 100,000 live births compared to a national rate of 38.2 (Observatory of Maternal Deaths in Mexico 2013). Chiapas is in many ways a unique place in Mexico. The Zapatista Army of National Liberation’s uprising in 1994 drew the world’s attention and the Mexican state’s interest to Chiapas’ million indigenous people (27% of the State’s population). In the past 20 years, the Mexican state has intensified its presence through government programs for farmers, road pavements, and the building of clinics. While these efforts have improved some living conditions, they have not always been successful. Still today, 74.7% of Chiapas’ population lives in poverty and extreme poverty (Secretary of Social Development, SEDESOL 2015).

Training indigenous midwives

In Highlands Chiapas, traditional indigenous midwives attend 70% of births. Following international guidelines from the WHO, the steps to diminish maternal mortality rates have focused on training these birth attendants. Mexican public health policies encourage practitioners in health centers and clinics to train the parteras in the detection of alarm signals; while on their end, parteras are urged to transfer their patients to hospitals.

The trainings for midwives focus on the opportune detection of alarm signals during pregnancy, birth and postpartum. The doctors and nurses who train them insist that the parteras learn these signals in order to recognize them and immediately transfer women to the nearest hospital. While opportune transfers have the potential to save the lives of the mother and child, government trainings do not discuss alternatives to transfer, in a context where the distance to the nearest hospital can often be of six or seven hours.

Given the cultural importance of birthing at home in Maya-speaking communities, surrounded by one’s family and in-laws, and with very little intervention, the shift from home to hospital is not only a change of physical place but also of space, social environment and language. In indigenous women’s and midwives’ accounts, the hospital is often described as an unfamiliar place with foreign codes; a dangerous place in which women are reluctant to give birth.

The coordinator of the Women and Midwives’ section of the Organization of Indigenous Doctors of Chiapas describes the impact of such trainings on the indigenous midwives, and the reasons why some of them slowly stop attending births:

It is like a rivalry that they are doing. It’s competition. For example… I attended this birth; but in reality no, I didn’t attend it totally. … I sent her to the hospital. If the baby is breeched for example, [the midwife will say] “It is breeched, better to go with the doctor… to go there, to receive her cesarean section.” This is what they tell women. Why? Because they have put a lot of things in her mind, in her heart… that the midwives once they have told us things, they believe it and start saying “Yes it is true that they die.” They tell them that they will send her to jail, that it will be her fault. They tell her “It is better that you don’t put yourself at risk by attending, better to send her to the hospital. It’s better. It is better in the hospital.” (Micaela Icó Bautista, Interview conducted by author, January 2014)

(Un)desired effects?

The paradox of insisting that parteras transfer women to hospitals is that even when they do so in cases of labor complications, they are still blamed for the situation. Parteras and mothers are scolded for attempting what is considered a risky birth — that is, trying to birth outside of the hospital. Because no one can enter with the laboring woman in public hospitals (midwives and husbands included), women will be on their own. Because the national policies urge midwives to send every woman to the hospital, public hospitals are saturated, and an efficient birth is a quick birth. The search for efficiency leads to routine episiotomies and skyrocketing C-section rates (Mexico now has the third highest C-section rate in the world).

Since there is a high chance women will be badly treated in hospitals, some parteras and family members refuse to send women to the hospital, even if they are able to identify the alarm signals. During births, parteras exert agency by evaluating the level of risk, comparing the risk of “something going wrong” and negatively affecting the mother and baby’s health, to the risk of going to the hospital and the bad treatment they and their patient might receive.

The negative impacts of training midwives touch at the root of the community’s health. When midwives stop attending births in their home communities, where they are the only health care providers, maternal and infant deaths will only increase. Despite international recommendations and government training programs, the reduction of maternal deaths in Chiapas will not be solved only by increasing the medicalization of birth. If the Mexican state does not focus on the root causes of such deaths — including structural violence, poverty, racism, and discrimination — indigenous women will continue to die in childbirth.

Les sages-femmes traditionnelles du Chiapas : Une approche holistique de la grossesse et de l’accouchement

[Originally published in Grandir Autrement, Hors-Série n9, 2015]

« Le don qu’a la sage-femme lui a été donné par Dieu. Ce n’est pas quelque chose de facile, d’accompagner un accouchement ; ce n’est pas pour n’importe qui… Car l’objectif principal est la vie du bébé et de la maman. Les sages-femmes travaillent jour et nuit, à n’importe quelle heure ; il y a constamment du travail pour les sages-femmes, et c’est maintenant qu’il faut transmettre ces connaissances pour le bénéfice de la maman et de sa famille. (…) Il ne faut pas perdre ces traditions médicinales, car elles se transmettent de génération en génération »

Ces paroles d’une sage-femme Maya ont été prononcées lors de la rencontre de sages-femmes traditionnelles de l’Organisation des Médecins Indigènes de l’Etat du Chiapas (OMIECH) en Février 2014. Depuis plus de trente ans, OMIECH compile et défend les savoirs des médecins traditionnels Mayas (Tseltals et Tsotsils) – guérisseurs et sages-femmes – depuis plus de trente ans, face à une médicalisation grandissante de la grossesse et de l’accouchement au Mexique (où près d’une naissance sur deux se fait par césarienne[i]). En effet, les aides gouvernementales aux familles pauvres obligent les femmes à pratiquer le suivi de leur grossesse par un médecin plutôt qu’une sage-femme traditionnelle, et à accoucher dans un milieu hospitalier plutôt qu’à leur domicile – ce qui est pourtant la norme culturelle. Pourtant, les sages-femmes traditionnelles restent des alliées incontournables pour les femmes de leur village. Elles connaissent parfaitement les conditions de vie de ces dernières, et savent les conseiller sur le plan nutritionnel, psychologique et physique. Elles n’hésitent pas non plus à marcher plusieurs kilomètres, quel que soit le climat ou l’heure du jour ou de la nuit, afin de répondre à l’appel d’une future maman.

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Dessin d’Alice Bafoin

Les mains au cœur de la pratique

Dans les villages des Hauts Plateaux du Chiapas, les sages-femmes traditionnelles accueillent plus de 70% des naissances. Leur principal outil de travail, ce sont leurs mains, qui, par le toucher, peuvent donner une date d’accouchement prévisionnelle, dévoiler le sexe du bébé, ou détecter un mauvais positionnement et replacer le bébé correctement. Mais les sages-femmes se basent également sur leur ample connaissance de leur écosystème et des propriétés des plantes médicinales, qui leur ont été transmises par les générations précédentes et au travers de leurs rêves, afin d’accompagner les femmes de leur communauté tout au long de leur grossesse, au cours de l’accouchement et pendant le postpartum.

Ainsi, dans les montagnes embrumées de cet Etat du Sud-Est du Mexique, les femmes Mayas qui se rendent chez leur sage-femme lui racontent les mauvais rêves qu’elles ont pu avoir, parlent de leur relation avec leur époux et leurs beaux-parents (chez qui les jeunes couplent habitent durant leurs premières années de mariage), et décrivent ce qu’elles ressentent dans leur corps. Ces conversations permettent à la sage-femme de conseiller la maman sur les aliments qu’elle devrait consommer, lui prescrire des recettes à base de plantes, d’expliquer au papa et à la belle-famille comment prendre soin d’elle, et parfois organiser une cérémonie afin d’éloigner les mauvais esprits et tranquilliser la famille.

L’importance de la chaleur

Pour les Mayas, la femme enceinte accumule de la chaleur au cours de sa grossesse. Lors de l’accouchement, la perte de sang équivaut à une perte de chaleur, un refroidis- sement qui peut être dangereux pour la maman. Le bon déroulement de l’accouchement est intimement lié à la création et au maintien d’un environnement chaud, qui rééquilibre la balance chaud/froid dans le corps de la femme. La sage-femme, qui s’est déjà rendue au domicile de la famille lors de visites prénatales, a repéré les plantes présentes aux alentours, et apporte dans son sac celles qui n’y sont pas et dont elle aura besoin. Les membres de la famille aident la sage-femme en faisant chauffer l’eau pour les différents thés et lavements, et maintiennent la chaleur de la pièce en alimentant constamment le feu. La future maman ne se dénude pas, elle garde sa blouse et sa jupe pendant le travail et l’accouchement. Elle alterne les positions, la plus classique étant d’être accroupie accrochée au cou de son époux, lui-même assis sur une chaise. Chez les Catholiques, la sage-femme accompagne l’événement par des chants, bougies, et prières. Après la naissance de l’enfant et du placenta, la maman reprend des forces en consommant un bouillon de poulet. Le placenta est enterré près de ou à l’intérieur de la maison. Après le repas, la sage-femme nettoie la pièce et les draps, et fait des recommandations à la famille sur les aliments à consommer. Elle reviendra rendre visite à la maman et au nouveau-né pour des visites postpartum dans les jours qui suivent.

Ces différents éléments thérapeutiques – chaleur, plantes, prières – ainsi que le respect de l’intégrité du corps de la femme (les sages-femmes effectuent peu ou pas de touchers vaginaux) contrastent avec le traitement que reçoivent les femmes qui accouchent dans les hôpitaux publics. Face à un personnel qui très souvent ne parle pas le Tsotsil ou Tseltal, seules dans un environnement froid, la modernité se paie au prix du confort et du respect du corps. C’est pour cela que de nombreuses femmes et familles refusent de se rendre à l’hôpital, malgré les pressions gouvernementales.

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Des ponts pour l’avenir

Malgré des études démontrant la sécurité d’un accouchement à domicile planifié pour les grossesses normales[ii], la médicalisation de l’accouchement est un phénomène global. En France, les changements timides tels que l’ouverture de maisons de naissance, ne doivent pas faire oublier la persécution que subissent les sages-femmes pratiquant l’accouchement à domicile[iii]. En France comme au Mexique, les sages-femmes et les familles s’organisent afin d’offrir aux mamans un accouchement ailleurs qu’à l’hôpital, et de préserver des savoirs respectant la physiologie du corps. Basée à Rennes, l’Association Mâ organise des échanges interculturels sur le sujet, en mettant en parallèle les luttes françaises et chiapanèques et en aidant l’Organisation des Médecins Indigènes du Chiapas à continuer d’organiser des rencontres de sages-femmes traditionnelles, afin que les bébés du Chiapas continuent à être accueillis par de si bonnes mains[iv].

[i] Chiffres de l’OCDE sur le site de l’association Césarine http://www.cesarine.org/avant/etat_des_lieux.php

[ii] Janssen, Patricia A., Lee Saxell, Lesley A. Page, et al. 2009. Outcomes of Planned Home Birth with Registered Midwife versus Planned Hospital Birth with Midwife or Physician. CMAJ : Canadian Medical Association Journal 181(6-7): 377–383.

[iii] Les Femmes sages. Syndicat National des Sages-Femmes pour l’Accouchement à Domicile http://snsfaad.weebly.com/

[iv] Pour plus d’information, vous pouvez consulter le Blog de l’Association Mâ http://blogdelassociationma.blogspot.fr/ et la page Facebook de la Section Femmes et Sages-Femmes d’OMIECH (en Espagnol) https://www.facebook.com/areademujeresomiech

Workshop on Plant Use and Women’s Reproductive Health

(Published in the Society for Medical Anthropology Newsletter, Second Opinion 3(2), 2015)

This series of pictures was taken in April 2015, while I was conducting fieldwork in Chiapas. My colleague and the founder of the Women and Midwives Section of the Organization of Indigenous Doctors of Chiapas. Micaela Icó Bautista, has been organizing workshops on women’s health for more than 30 years with Tseltal and Tsotsil healers and midwives in communities of Highland Chiapas. As a volunteer for her, I served as the photographer on this occasion while she asked questions and stimulated the conversation in Tsotsil.

This workshop was hosted at a traditional midwife’s house, and we were surprised by the number of people who came, especially the men. With about 40 adults, this was a particularly big audience.

Before it starts, Micaela, the midwife, and her son-in-law went into the milpa (cornfield) behind the house to look for some medicinal plants that could be discussed during the workshop.

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Micaela and the midwife’s son-in-law in the milpa

Unlike government or other NGO workshops modeled on a top-down relationship between the facilitator and the audience, Micaela uses popular education tools and acts as a catalyst for the conversations. That way, the participants each share their experience and medical knowledge about a topic. Our original idea for the workshop was to talk about menopause. During the icebreaker, however, other concerns emerged, so we started by addressing these issues.

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Micaela giving instructions for the icebreaker. Participants are placed within a rope circle and then move together as a group toward the diseases they want to eradicate.

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Micaela talking to the group. In the background, the poster paper with plant recipes to treat some of the diseases discussed during the Icebreaker.

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A woman sharing her experience during the workshop. Children follow their parents, especially their mothers, during daily activities. The fertility rate for indigenous women who are 35 and older is 6.1.

 

After the workshop, the recipes are left at the midwife’s house for everyone to consult. In her office, Micaela goes through the audios and notes taken during the workshops in the different communities, and edits booklets compiling the recipes in order for the community to keep transmitting its knowledge.

 

Notes from the field

(Published in the Council on Anthropology and Reproduction Newsletter 22(2), 2015)

“Oh, I see, so you want to be a partera (midwife)” is the typical response I hear after explaining the purpose of my visit; that I am doing dissertation research to document how midwives live and work. Although I try to explain my research goal in terms of “helping raise awareness on the difficulties parteras are facing,” I am always met with this same response “so you want to learn how to become a midwife?” And as I have gotten to met parteras and aspiring midwives, I must admit that there is not always a clear difference between what I do and how I act and what they do and how they act: asking questions about pregnancy care, sitting in on prenatal consults, taking notes on almost everything the partera says… There is a thin line between participant-observation and midwives’ apprenticeship model. And indeed, I have been learning a lot about how parteras work and live, but also a hell of a lot about plants given in pregnancy care and massage techniques.

Since October 2014, I have been in San Cristóbal de Las Casas, Chiapas, conducting dissertation fieldwork and volunteering for the Women and Midwives’ Section of the Organization of Indigenous Doctors of Chiapas (OMIECH). As a volunteer, my work consists mainly of two tasks: administrative tasks (aka looking for funding) and logistical support during events and workshops. Since 1985, OMIECH has been strengthening Mayan medical knowledge and organizing health workshops in indigenous Tseltal and Tsotsil communities of Chiapas. Even though I am in Chiapas, some of my notes echo those of Kara E. Miller (Fall 2014 Newsletter). Here too, the parteras – who are referred to as Traditional Birth Attendants in international documents – are frustrated with the lack of possibilities to transfer their skills to the next generation. This is why the Women and Midwives’ section organizes workshops focused on reproductive health, and care during pregnancy, birth, and postpartum. These workshops are open to all members of the community where they take place, and aim to perpetuate botanical and medical knowledge by transmitting it to younger generations.

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Picture 1. Tsotsil partera during a community workshop. Photo by author.

The loss of knowledge is accelerated by various factors (young people’s migration, midwifery not an attractive profession economically), one of them being the medicalization of birth. The push to send women to birth in hospitals comes with a deligitimation of indigenous parteras’s knowledge as “not-modern”. Through conditional cash-transfer programs (documented by Vania Smith-Oka in the state of Veracruz), women are pushed to have their prenatal visits and give birth in hospitals. Parteras, on their end, have to attend trainings given by the Health Secretary. These trainings have emerged in the 1980s, and intensified in Chiapas under the pressure of reducing maternal mortality rate to comply with the Millennium Development Goal (Chiapas has one of the highest maternal mortality rates in Mexico). Indigenous traditional midwives either have to follow the trainings or stop practicing. This can have dramatic consequences in places where they are often the only health care provider in their communities.

As I jot down notes during an interview or observation within these different settings, I feel a thrill of delight when their words echo one another. But then I realize this means that these state policies are really achieving great changes for parteras. And like Sisyphus, tirelessly, my colleagues at OMIECH reweave what is being unwoven: traditional medical knowledge, but also, and as important, pride in it and trust within the community.

While “in the field”, my notes are scribbly at times, crystal clear at others, but rarely absent. I try to type them regularly, as a good apprentice-anthropologist, but have stopped feeling guilty when I could not do so. It took me a few months to be able to “let go” and admit there will always be an event I will miss, a trip I cannot make… At my mid-point in the field (already), I have just started to take drawing classes, which helps me expand the range of my notes, when words fail to describe a hand gesture, or when I do not know the terminology for this exact point on the belly that needs to be massaged. These classes have made the familiar look different, and made me look at people in a new way, which in turns adds more depth to my notes.

Life in the field intertwines professional, political and personal spheres. The friendships I have built through this research promise to impact both my career and personal life. As we were searching for plants in the garden of the organization for an upcoming booklet publication, my colleague Micaela corrected me as I got the name of the plant wrong, once again. I could sens, for the first time, an impatient tone in her voice. I pause and I suddenly realized that although I am not studying to become a midwife, every one of the parteras I have met have been a teacher to me, training me a little bit, sharing their story, their tortilla and their endless knowledge. I am looking forward to learning a lot more in the next five months I will be spending with them and I hope my dissertation will bring them knowledge they can use in their struggle.