[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.

 

[ 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.

[ PUBLICATION ] 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.

Rezo
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

[ WRITING ] 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.