[ PUBLICATION ] Politiques de santé materno-infantile au Brésil et au Mexique

avec Alfonsina Faya Robles, Cahiers des Amériques Latines 88-89, 2018, pp.61-78.

Au Mexique et au Brésil, les femmes pauvres sont la cible privilégiée de politiques de santé materno-infantiles. Dans le premier contexte, elles bénéficient d’une aide financière en échange de leur participation à des ateliers de santé et à des visites médicales. Dans le second, elles sont inscrites dans des programmes de santé pendant leur grossesse, accouchement et post-partum. L’analyse croisée des données d’enquêtes menées auprès de femmes de quartiers populaires, de sages-femmes traditionnelles, d’agent.e.s communautaires de santé et de personnel médical met en avant deux processus connexes de régulation des choix reproductifs : la médicalisation de la santé reproductive et la sanitarisation des corps féminins. Nous montrons comment le développement de l’assistance médicale et sanitaire dans ces deux pays, au-delà des changements positifs, soumet les décisions reproductives au contrôle d’agents étatiques de santé, renforçant les mécanismes de régulation et de domination des (corps des) femmes pauvres.

La suite sur https://journals.openedition.org/cal/8837

[ PUBLICATION ] Maltraitance des corps et mépris des pratiques culturelles

Article paru dans Actualité Sages-Femmes n93, Octobre 2018

Maltraitance des corps et mépris des pratiques culturelles dans les maternités publiques au Mexique.

« Ce sont comme des usines. Les femmes, ils nous traitent comme si on était des poules ou des animaux. “Mettez-la ici, et l’autre là” [disent les médecins], comme si on était… ». Alma avait 17 ans lorsqu’elle accouche pour la première fois, dans une clinique publique de San Cristóbal de Las Casas, la capitale culturelle de l’Etat du Chiapas, dans le Sud du Mexique. La jeune femme d’origine Tseltal[i] est née à domicile, dans un village près de San Cristóbal, où elle vit à présent. Les maltraitances qu’elle a vécues lors de son premier accouchement (violence verbale, actes non consentis) l’ont poussée à chercher une alternative lors de sa deuxième grossesse. Son deuxième accouchement a ainsi eu lieu dans une maison de naissance de la ville : « Contrairement à ma première grossesse, je connaissais le processus, je savais comment cela allait se passer. Mais je n’avais plus peur. J’étais très contente car je savais que mon conjoint, mon père et ma mère allaient être présents. Cela m’a rassurée ».

J’ai rencontré Alma lors d’une enquête sur l’impact des politiques de santé maternelle, et en particulier celles portant sur la formation des sages-femmes traditionnelles et sur l’accès aux soins des femmes, menée entre 2013 et 2015 dans le Chiapas[ii]. Au cours de cette recherche, j’ai conduit plus d’une centaine d’entretiens avec des sages-femmes traditionnelles, des travailleur-se-s de santé, des médecins, des obstétricien-ne-s et des familles dans plusieurs régions du Chiapas. J’ai également mené neuf mois d’observation-participante auprès de l’Organisation des Médecins Indigènes du Chiapas (OMIECH) qui organise des ateliers de santé communautaire, et partagé le quotidien de trois sages-femmes traditionnelles.

Dans les zones rurales du Chiapas, les sages-femmes traditionnelles accueillent environ 70% des naissances, contre moins de 20% au niveau de l’Etat. Ces femmes ont acquis leurs connaissance par le biais d’apprentissage onirique (elles reçoivent leurs connaissances à travers leurs rêves) et/ou empirique (à la suite de nombreuses grossesses ou en accompagnant leurs parentes sages-femmes)[iii]. Le suivi de grossesse se déroule au domicile de la femme enceinte ou de la patiente (Image 1), et l’accouchement a lieu chez la patiente, qui vit elle-même avec sa belle-famille. L’accouchement est un événement qui requiert beaucoup de chaleur (feu, tisanes, massages) pour contrebalancer la perte de fluide. Tout au long du travail, la patiente ne se dénude pas, elle reste vêtue, et la sage femme n’effectue pas ou peu de touchers vaginaux. La patiente se déplace dans la pièce, et est souvent libre d’essayer plusieurs positions d’accouchement, la plus commune étant sur les genoux, les bras autour de l’époux (ou une autre personne) assis sur une chaise.

Depuis les années 1990, la médicalisation de l’accouchement s’est accélérée au Mexique, en étroit lien avec les objectifs de diminution de la mortalité maternelle[iv]. Au cours des 25 dernières années, la proportion de naissances en milieu hospitalier est ainsi passée de 22,4% à 72,9 %[v]. Cette médicalisation de la santé reproductive des femmes pauvres repose sur deux mécanismes. D’une part, les femmes enceintes sont captées par le système de santé public dès le début de la grossesse par le biais du programme de transfert monétaire Prospera, qui vise à lutter contre la pauvreté par un principe de « co-responsabilité ». Les bénéficiaires de Prospera doivent par exemple se rendre à des ateliers de santé mensuels dans les cliniques ou encore réaliser leur suivi de grossesse au sein du système de santé, sous peine de se voir radiées du programme et de perdre ainsi un apport économique important. Les visites prénatales obligatoires socialisent les femmes à la biomédecine. Lors de ces visites, les médecins encouragent leurs patientes à accoucher dans des maternités plutôt qu’à domicile. De leur côté, les sages-femmes traditionnelles sont elles aussi captées par le système de santé, puisqu’elles doivent suivre des formations mensuelles dispensées par le personnel des cliniques rurales (Image 2), qui les encourage à transférer leurs patientes vers le système de santé public[vi].

Or, lorsqu’elles se rendent dans les hôpitaux publics, les femmes que j’ai rencontrées au cours de mon enquête se sont plaintes d’avoir été confrontées à des barrières de langue, aux remarques racistes et sexistes du personnel ainsi qu’à des violences physiques, psychologiques et verbales. Si certaines expériences sont violentes en elles-mêmes, d’autres relèvent d’une méconnaissance voire de mépris envers les pratiques socio-culturelles de l’accouchement, pouvant négativement impacter l’expérience des femmes Mayas, comme détaillé ci-dessous.

nudité : lorsqu’elles accouchent à la maternité, les femmes doivent quitter leurs vêtements au profit d’une blouse. Le froid ressenti, en opposition avec la chaleur du feu lors d’un accouchement à domicile, ainsi que face à l’exposition du corps nu au regard de plusieurs inconnu-e-s sont deux critiques souvent faites par les femmes[vii].

langue : dans une nation pluriculturelle où 69 langues officielles sont reconnues, les patientes et les médecins viennent parfois de contextes socioculturels très différents. Les jeunes médecins qui étudient dans les grandes villes du pays effectuent leur internat dans tout le Mexique et ne parlent souvent pas la ou les langue(s) locale(s). Le Chiapas fait également partie des Etats avec le plus grand nombre de personnes indigènes monolingues (jusqu’à 78% dans certains villages). Dans ce contexte, il est difficile non seulement de communiquer mais aussi de recueillir le consentement des patientes.

solitude : dans les maternités publiques, aucune personne n’est autorisée à accompagner la parturiente, qui se retrouve donc seule. La difficulté de communication avec le personnel de santé renforce le sentiment de solitude.

mépris socio-culturel : les pratiques médicales indigènes peuvent être moquées par le personnel de santé, ainsi que les conditions de vie des femmes pauvres. La coordinatrice de l’association OMIECH, décrivait ainsi « les médecins disent que les sages-femmes sont sales, parce qu’elles ne portent pas de gants, parce que leurs maisons sont humbles ». Certaines pratiques thérapeutiques des sages-femmes traditionnelles, comme la version céphalique externe ou l’utilisation du bain de vapeur (temascal), sont également sous le feu des critiques par le personnel médical. Lorsque les femmes arrivent à la maternité, il arrive régulièrement que le personnel leur demande si elles ont été « manipulées par une sage-femme ».

toucher vaginal : ce geste invasif, réalisé de manière routinière[viii], est celui qui ressort le plus souvent dans les récit des femmes. Pour les sages-femmes Mayas, qui en effectuent peu ou pas, ces touchers intempestifs sont agressifs, comme le décrivait l’une d’entre elles lors d’un atelier organisé par OMIECH, « [Les femmes] ne sont pas des poules, je n’ai pas besoin de vérifier si l’œuf va sortir ».

épisiotomie : les femmes que nous avons rencontrées ont éxprimé leur peur de la « petite coupure » (épisiotomie), systématique dans les maternités mexicaines. Une sage-femme Tsotsil de 70 ans décrivait les pratiques hospitalières de la façon suivante : « on te coupe, et ensuite on te coud comme un torchon ». Pour Alma, qui a accouché pour la première fois dans une clinique publique à l’âge de 17 ans, le plus douloureux souvenir a été son épisiotomie « Oui. Ça c’est le plus moche… Moi je me dis que les médecins font des épisiotomies car c’est plus facile. Mais je ne suis pas d’accord, je pense que notre corps sait ». Dans les hôpitaux publics, ce sont souvent des internes qui pratiquent les épisiotomies, certain-e-s pour s’entraîner, comme nous le confiait un médecin généraliste à la retraite.

césarienne : la « grande coupure » représente pour certaines sages-femmes une violation à l’intégrité du corps. Une sage-femme Tseltal de 70 ans nous racontait refuser de se rendre à la maternité pour donner naissance : « Je pensais que j’allais mourir, j’étais si triste. J’ai dit ‘tant pis, il vaut mieux que je meurs. Car s’ils me coupent je vais souffrir’ Je ne voulais pas me faire opérer ». Cette peur de la césarienne est également à mettre en parallèle de la plus grande probabilité (40%) qu’ont les femmes indigènes de donner naissance par césarienne, pour des raisons liées à leur participation au programme Prospera (qui médicalise toutes les grossesses) ou les biais du personnel médical, qui préfère les opérer lorsqu’elles arrivent à la clinique en début de travail, par peur qu’elles ne reviennent pas si elles sont renvoyées chez elles (les maternités manquent de place et il est fréquent de faire patienter les femmes en pré-travail (voire en phase active) de longues heures en salle d’attente, ou de les renvoyer chez elles)[ix].

contraception et stérilisation forcée : la Commission Nationale pour Prévenir et Eradiquer les Violences faites aux Femmes (CONAVIM) estime que plus du quart des femmes indigènes qui ont été en contact avec les institutions de santé auraient été stérilisées sans leur consentement[x]. J’ai recueilli des récits de contraception forcée, notamment celui d’Estela, une mère de 20 ans, à qui le personnel de la maternité publique n’a autorisé la sortie que sous condition de pose d’implant. La contraception hormonale est fortement critiquée par les sages-femmes traditionnelles. Elles accusent les hormones de rendre les femmes malades, stériles, ou de refroidir la matrice. Elles leur préfèrent les plantes médicinales, dont elles ont une connaissance extensive.

Vers une bientraitance des patientes ?

Malgré les programmes gouvernementaux encourageant les femmes pauvres à accoucher dans les maternités plutôt qu’à domicile, les sages-femmes traditionnelles accueillent toujours la majorité des naissances dans les zones rurales. La persistance de l’accouchement à domicile peut alors être interprétée comme un élément central de la reproduction physique et culturelle des communautés. Le respect de l’intégrité du corps, la communication dans la langue maternelle et l’entourage de la famille sont des éléments fréquemment évoqués par les femmes et les sages-femmes dans leur critique des pratiques hospitalières.

La loi du Chiapas condamne les violences obstétricales, mais en pratique elle est difficilement applicable. D’autres mesures sont développées afin d’améliorer les conditions d’accouchement dans les maternités publiques.

Ainsi, la formation d’une nouvelle génération de sages-femmes professionnelles amenées à être intégrées au système de santé mexicain permet de créer un pont entre les femmes et les praticien-ne-s. J’ai ainsi interrogé une sage-femme Tsotsil d’une trentaine d’années, d’abord formée dans son village comme sage-femme traditionnelle puis dans une des seules écoles de sages-femmes professionnelles du pays. Lors de son stage dans une maternité aux alentours de San Cristóbal, où les médecins ne parlaient qu’Espagnol, sa maîtrise du Tsotsil lui a permis d’expliquer les procédures aux patientes. « Il y avait beaucoup de femmes dont l’unique option était la césarienne parce qu’elles avaient des complications. Mais elles ne voulaient pas, et moi je réussissais à les convaincre, parce que c’était l’unique option pour elles, pour leur bébé ». Les femmes consentent alors aux actes médicaux après avoir reçu une explication dans leur langue maternelle, les rassurant sur leurs peurs.

Au sein des hôpitaux publics du Chiapas, les formations pour le personnel incluent une formation sur l’interculturalité, dispensée par un médecin parlant Tseltal et Tsotsil. Cette formation permet de déconstruire les préjugés sur les patient-e-s indigènes et d’améliorer leur accueil.

Enfin, l’association OMIECH milite depuis 30 ans pour la reconnaissance des savoirs des médecins indigènes et sages-femmes traditionnelles et organise des ateliers de santé communautaire afin de favoriser la transmission aux jeunes générations.

Notes

[i] Dans le Chiapas, environ un quart de la population est indigène. Les deux ethnies majoritaires sont les Tseltal et les Tsotsil.

[ii] Mounia El Kotni, « Porque Tienen Mucho Derecho. » Parteras, Biomedical Training and the Vernacularization of Human Rights in Chiapas, Ph.D. Dissertation, University at Albany, SUNY, Albany, N.Y, 2016, 295 p.

[iii] Área de Mujeres y Parteras, La Partera. Jnet’um, San Cristóbal de Las Casas, OMIECH, 1988, 9 p.

[iv] En 2014, l’Etat du Chiapas avait le deuxième taux le plus élevé de mortalité maternelle du pays, soit 68,1 pour 100 000 naissances vivantes, contre 38,1 au niveau national (avec un objectif de 22,2 fixé par les Objectifs Millénaires du Développement).

[v] Observatorio de Mortalidad Materna en México, Indicadores 2013. Objetivo de Desarrollo del Milenio 5: Avances en México, México, D.F y San Cristóbal de Las Casas, Chiapas, OMM, 2015.

[vi] Mounia El Kotni, « Regulating Traditional Mexican Midwifery: Practices of Control, Strategies of Resistance », Medical Anthropology: Cross Cultural Studies in Health and Illness, A paraître.

[vii] Midiam Ibáñez-Cuevas et al., « Labor and delivery service use: indigenous women’s preference and the health sector response in the Chiapas Highlands of Mexico », International Journal for Equity in Health, 23 décembre 2015, vol. 14, p. 156.

[viii] Vania Smith-Oka, « Managing Labor and Delivery among Impoverished Populations in Mexico: Cervical Examinations as Bureaucratic Practice », American Anthropologist, 2013, vol. 115, no 4, p. 595‑607.

[ix] María Graciela Freyermuth, José Alberto Muños et María del Pilar Ochoa, « From therapeutic to elective cesarean deliveries: factors associated with the increase in cesarean deliveries in Chiapas », International Journal of Equity in Health, 2017, vol. 16, no 88, p. 1‑15.

[x] Proceso, « El 27% de mujeres indígenas esterilizadas sin su consentimiento: Conavim. », Proceso, 14 févr. 2013.

[ PUBLICATION ] Socio-Cultural Approaches to the Anthropology of Reproduction

An edited bibliography curated by Elise Andaya and Mounia El Kotni, available at http://www.oxfordbibliographies.com/abstract/document/obo-9780199766567/obo-9780199766567-0197.xml

Introduction

Attention to reproduction within anthropology emerged in early cross-cultural studies, largely descriptive and ethnomedical in nature, that examined reproduction in the context of cultural and religious beliefs around conception, childbirth and postpartum taboos, and knowledge about fertility regulation. However, the topic was given a new theoretical framing and disciplinary significance beginning in the 1980s when feminist scholars built on prior work on gender and kinship to articulate a new field of analysis that firmly situated reproduction at the nexus of power and politics. As Faye Ginsburg and Rayna Rapp argued in their article, “The Politics of Reproduction” (Ginsburg and Rapp 1991, cited under Early Conceptual Frameworks and Edited Volumes) that demarcated this new field that they called the “politics of reproduction,” biological and social reproduction are inextricably intertwined.

[REVIEW] Midwives and Mothers: The Medicalization of Childbirth on a Guatemalan Plantation

[Originally published on August 8, 2018 on the Association for Feminist Anthropology website]

Midwives and Mothers: The Medicalization of Childbirth on a Guatemalan Plantation, Sheila Cosminsky, University of Texas Press, 2016, 303 p.

Midwives and Mothers builds on Sheila Cosminsky’s decades-long involvement with midwives in Guatemala, where she has been conducting research since 1974. This thoroughly documented monograph provides a rich account of the changes and continuities in women’s reproductive care preferences and midwives’ practices in rural Guatemala. Cosminsky analyzes the shifting roles of midwives across generations by contrasting midwife Maria’s work in the 1970s to her daughter Siriaca’s, also a midwife on the coffee and sugar plantation where she grew up.

As indicated in the Acknowledgements, it is a feeling of urgency that led the author to publish this monograph, an urgency fueled by the ongoing criticism and attacks by biomedical personnel and international organizations towards traditional midwives’ knowledge and practices. The increased pressure to medicalize pregnancy and birth deeply impact women’s experiences and midwives’ practices, as described in the nine chapters of this monograph.

Each chapter contains rich ethnographic descriptions, details on international and national health policies, and theoretical analysis from the fields of medical anthropology, the anthropology of reproduction and midwifery studies. The first three chapters provide information on the context of the study: Chapter 1 introduces the reader to midwives’ role in Maya communities, Chapter 2 describes the Finca and María’s work, and Chapter 3 contrasts María and Siriaca’s practices and relations to their patients. The following three chapters dive deep into describing midwives’ work in prenatal care (Chapter 4), pregnancy (Chapter 5) and postpartum (Chapter 6), contrasting the changes between mother and daughter’s practices, and in the relations between midwives and health institutions. Chapter 7 focuses on the role of the midwife, whose scope of practices range far beyond pregnancy and birth, while Chapter 8 and 9 respectively interrogate national midwifery policies and one of their consequences, the medicalization of childbirth.

The changing role of midwives

Across Guatemala, midwives attend two third of births, a rate reaching 80 percent in rural areas. Cosminsky analyzes midwives’ daily practices in relation to various socio-political spheres, including local cultural norms, political relations between midwives and Finca owners, national midwifery training programs and international policies aiming at diminishing Guatemala’s high maternal mortality rates. This ethnography also highlights how, on their end, Maya women’s reproductive health decisions are made at the nexus of various structural factors, personal decisions, family preferences and public health messages.

Taken together, the chapters provide a large overview of midwives’ diverse scope of practices, from prenatal care, labor and delivery to infant care and family counselors, leading the author to describe these women as “doctors to the family.” While previous ethnographies on and with midwives in Mexico and Guatemala also describe the many roles midwives undertake (Berry 2010, Freyermuth 2003, Jordan 1993), Cosminsky devotes entire chapters to one or the other aspect of midwives’ work, providing a comprehensive description of midwives’ large scope of practice. The fruitful comparison of midwives-as-family-doctors grounds these women’s work in the everyday life of Maya men and women and provides a glimpse both at their material living conditions and the health challenges they face.

Cosminisky’s long-standing involvement with midwives appears through detailed ethnographic vignettes, providing an intimate view on the relations between midwives and their patients, as well as in the detailed list of diseases—ethnocultural and biomedical alike—these women cure. While I appreciate the level of detail provided by the vignettes, my work with the Organization of Indigenous Doctors of Chiapas (OMIECH)—at the forefront of political opposition to biopiracy in Southern Mexico—lead me to be wary of listing medicinal plants and recipes as they are presented in the Appendices. Debates on plant knowledge property are strong in both research and activist communities, and this monograph, published in English, is directed towards non-community members, raising concern on the use of such knowledge. Providing a translation of the Appendices and sharing it with community members might be one way of returning the knowledge to those who provided it, as OMIECH has done in Chiapas.

The medicalization of childbirth in Guatemala

Cosminsky’s ethnography is also a political analysis of the medicalization of childbirth in Guatemala, and the everyday consequences of midwifery training programs on midwives’ medical practices and women’s birth experiences. Descriptions of midwifery trainings highlight how international guidelines impact relations between medical staff and midwives, and change the way midwives manage birth. The author expresses concern for the continuous attacks on midwives’ practices by biomedical personnel. For example, midwives are not allowed to attend primiparous women, which restricts midwives’ scope of practices and can come into conflict with cultural expectations and women’s desires. Despite such regulations, women resist giving birth in hospitals, for fear of mistreatment and abuse – a fear shared by several women throughout the book.

Broader impact

The moral dilemmas Guatemalan midwives face, between biomedical recommendations and their empirical knowledge resonate with midwives’ situation across the world. The medicalization of reproductive health is of growing concern by scholars, activists and international organizations. This ethnography provides a case study of the rapid changes in midwives’ practices, and their far-reaching consequences not only for women but for entire communities. It is a valuable resource for teaching undergraduate and graduate courses alike, in Anthropology, Nursing and Midwifery, Latin American Studies and Public Health. The different chapters can be used separately or as a whole, providing an excellent example of ethnographic research and writing.

 

References

Berry, Nicole S. 2010 Unsafe Motherhood: Mayan Maternal Mortality and Subjectivity in Post-War Guatemala. Reprint edition. New York: Berghahn Books.

Freyermuth, Graciela 2003      Las mujeres de humo: morir en Chenalho : género, etnia y generación, factores constitutivos del riesgo durante la maternidad. México, D.F: CIESAS, INM, Comité por una Maternidad Voluntaria y sin Riesgos en Chiapas.

Jordan, Brigitte 1993 Birth in Four Cultures : A Crosscultural Investigation of Childbirth in Yucatan, Holland, Sweden, and the United States. 4th edition. Prospect Heights, Ill: Waveland Pr Inc.

[ PUBLICATION ] Structural Violence: An Important Factor of Maternal Mortality Among Indigenous Women in Chiapas, Mexico

[Book Chapter published in Schwartz, David (ed) 2018 Maternal Health, Pregnancy-Related Morbidity and Death Among Indigenous Women of Mexico & Central America: An Anthropological, Epidemiological and Biomedical Approach, Springer, pp.147-167]

Abstract  In Chiapas, Mexico’s poorest state, indigenous Mayan women are twice more likely to die in childbirth than are non-indigenous women. To comply with international development goals and diminish Chiapas’ high maternal mortality rates, indigenous midwives are trained in detecting risk factors in pregnancy and birth, while women are encouraged to give birth in hospitals. This chapter analyzes the consequences of such policies, which might unintentionally exacerbate the structural violence indigenous women face in their lives. In Chiapas, 74.7 percent of the population lives in poverty and extreme poverty, compared to the national 43 percent rate. This extreme poverty, together with the lack of infrastructure and engrained racism, are all factors reproducing violence in the lives of poor women. In the state, the maternal mortality rate of women in reproductive age group has increased between 2010 and 2013, and that of indigenous women has almost doubled (1.7 times) over the same time period. Using an anthropological approach, this chapter examines the institutional and cultural changes in childbirth practices that are occurring in Highlands Chiapas, and sheds a light on the structural factors that expose Mayan women to unsafe births, increasing the likelihood that they will suffer mistreatment in childbirth.

 

Ostrach book cover

[ REVIEW ] Ostrach, Bayla 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.

[ PUBLICATION ] 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.