[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.