ANTH 4409 Idaho State University Clinical Medical Anthropology Article Review

Medical Anthropology Cross-Cultural Studies in Health and Illness ISSN: 0145-9740 (Print) 1545-5882 (Online) Journal homepage: Regulating Traditional Mexican Midwifery: Practices of Control, Strategies of Resistance Mounia El Kotni To cite this article: Mounia El Kotni (2018): Regulating Traditional Mexican Midwifery: Practices of Control, Strategies of Resistance, Medical Anthropology, DOI: 10.1080/01459740.2018.1539974 To link to this article: Published online: 21 Nov 2018. Submit your article to this journal Article views: 84 View Crossmark data Full Terms & Conditions of access and use can be found at MEDICAL ANTHROPOLOGY Regulating Traditional Mexican Midwifery: Practices of Control, Strategies of Resistance Mounia El Kotni Department of Anthropology, State University of New York at Albany, Albany, New York, USA ABSTRACT KEYWORDS The institutionalization of Mexican midwifery has a long history. Despite global recommendations moving away from training traditional midwives, training courses still continue. Based on fieldwork in the State of Chiapas, I argue that while ongoing trainings offered to traditional midwives in Mexico aim at teaching them best practices, they also limit midwives’ autonomy and keep poor women’s reproductive behaviors under control. I demonstrate how midwives and medical personnel mobilize discourses of reproductive risk, women’s rights and indigenous cultural rights to reinforce or contest mechanisms of reproductive governance. Mexico; childbirth; human rights; indigenous rights; midwifery; reproductive governance “Our midwives don’t attend complicated births, this is why maternal mortality has diminished here.” This is how Dr. Andrés1 described the success of the capacitaciones (training courses for traditional midwives) in the rural health center he manages in the municipality of Oxchuc, Chiapas. Chiapas is Mexico’s poorest state, with over three quarters of the population living in poverty and extreme poverty. It also has one of the country’s highest maternal mortality rates (68.1 per 100,000 births in 2015 in Chiapas; 36.1 nationally) despite the nation’s strong commitment to advancing the Millennium Development Goals (MDGs) set forth by the United Nations in 2000 (OMM 2016). Dr. Andrés’ monthly trainings for traditional midwives2 include a wide range of topics, “but always with a focus on risk,” he added. In this rural indigenous municipality with a 93% poverty rate (SEDESOL & CONEVAL 2015), training courses have focused on the detection of danger signs in pregnancy and childbirth and on encouraging midwives to transfer their patients to the health center in the case of danger to mothers and babies. In many aspects, capacitaciones limit traditional midwives’ agency as health care providers and as women, contributing to the displacement of their medical knowledge toward the margins of the reproductive health care system. The discourse of Dr. Andrés focuses on midwives’ responsibilities in diminishing maternal mortality, implying that maternal deaths can be attributed, to a certain extent, to these women’s care. In this article, I examine how capacitaciones become a contested site for different actors (state employees, health personnel, nongovernmental organizations) to push their own agenda. I argue that the ongoing trainings offered to traditional midwives in Mexico aim at teaching them best practices, but in the process limit midwives’ autonomy and keep poor women’s reproductive behaviors under control. Through my analysis, I demonstrate how midwives and medical personnel mobilize discourses of reproductive risk, women’s rights, and indigenous cultural rights to reinforce or contest mechanisms of reproductive governance. CONTACT Mounia El Kotni [email protected] 1400 Washington Ave., Albany, NY 12222, USA © 2018 Taylor & Francis Group, LLC Department of Anthropology, State University of New York at Albany, 2 M. EL KOTNI Controlling traditional midwives’ practices: Between global injunctions and local strategies Traditional midwives are women who became midwives through apprentice-style learning (by attending their own births and/or those of other women) and do not possess a formal, institutional training in midwifery. As older, often indigenous women with little formal education, traditional midwives care for women with whom they share many socioeconomic characteristics; in rural areas, midwives and their patients are often part of the same extended family networks. The Mexican Committee for Safe Motherhood estimated in 2014 that there are about 15,000 traditional midwives in the country (Comité Promotor por una Maternidad Segura en México 2014). However, according to the Organization of Indigenous Doctors of the State of Chiapas (OMIECH), an organization promoting indigenous medical knowledge, this number is largely underestimated (personal communication). While today traditional midwives attend less than 4% of births in the country, in indigenous and rural areas of Mexico, the care they provide covers up to 75% of births (Sesia 2015:113). In indigenous communities, traditional midwives play an important social, medical, and religious role (Área de Mujeres y Parteras 2004; Freyermuth 2003). Their practices are protected under Article 4 of the Mexican constitution, which recognizes indigenous peoples’ cultural rights, and in the 1992 Constitution, which recognizes indigenous usos y costumbres [law and customs]. However, these laws imply that midwives’ knowledge is strictly cultural. This prevents midwives from being considered “technical birth attendants” (health personnel with formal institutional training), the type of midwives promoted by international organizations (UNFPA 2014). The push for training traditional midwives began in the first half of the twentieth century. In the 1930s, the 10th Pan American Health Conference recommended that health authorities educate and monitor midwives’ practices (Oficina Sanitaria Panamericana 1938). In the 1940s and 1950s, midwives were identified as key agents in the implementation of tropical disease prevention programs (Asociación Americana de Salud Pública 1955). In 1978, the conference of Alma Alta introduced a new rights-based approach to debates on health policy. This approach was emphasized in international maternal health programs such as the Safe Motherhood Initiative (SMI), launched in 1987, which frames maternal mortality as a violation of women’s rights to health (for an in-depth discussion of the SMI, see: Berry 2010). In the context of the SMI, traditional midwives became the main figure of the fight against maternal death. To reduce maternal mortality rates, training sessions targeting traditional midwives and focusing on asepsis and hygiene were implemented globally (Jordan 1989). However, these training courses were considered only an interim measure, until all women could be attended exclusively by biomedically skilled personnel (Kruske and Barclay 2004). Since the introduction of the concept of reproductive rights following the Cairo Conference (1994), maternal mortality reduction strategies have framed maternal mortality as a violation of reproductive rights, and included the development of emergency obstetrics response networks in rural areas (Berry 2010; Freyermuth 2015). The MDGs set forth in 2000 relied on 2 indicators to improve maternal health: the diminution of maternal mortality rates by 75% (target 5.A) and universal access to reproductive health care (target 5.B). During the 15 years of the MDGs, global strategies shifted away from the training of traditional midwives, now considered to have had little impact on maternal mortality metrics, and international organizations redirected funding to support the medical training of a new generation of “skilled midwives” (Comité Promotor por una Maternidad Segura en México 2014). In her 2015 speech at the Global Maternal and Newborn Health Conference in Mexico City in 2015, co-organized by UNFPA, UNICEF, and international NGOs, Melinda Gates pleaded: Quality care at facilities is one of the absolute keys to saving mothers and newborns. So we need to continue to ensure that we are satisfied and that those Skilled Birth Attendants are staffed at all clinics for women. That the clinics themselves are well-supplied and well-trained, so that we can make childbirth even safer. (GMNHC 2015) MEDICAL ANTHROPOLOGY 3 In a post-MDG/Sustainable Development Goals context, traditional midwives are no longer perceived as playing an important role in combating maternal mortality (Freyermuth 2015). At the national level, however, the long-standing will of Mexican authorities to assimilate and control indigenous practices (Joseph and Nugent 1994) can account for the continuity of traditional midwife training in the country. The institutionalization of Mexican midwifery began in the nineteenth century, born out of a will to control midwifery practices and subordinate them to medical birthing practices (Jaffary 2016). However, and despite restrictions on their practice, traditional midwives continued to be the main providers of care during pregnancy, childbirth, and postpartum late into the twentieth century. In their analysis of the evolution of global health discourses on traditional midwifery, Argüello-Avenda ño and Mateo-González (2014) report the persistence of the Ministry of Health’s efforts to control midwives’ practices, deemed dangerous for women. From the 1930s to the present day, policies directed toward traditional midwives still stem from a belief that their practices are dangerous and need to be controlled (Argüello-Avendaño and Mateo-González 2014; Cosminsky 2012). Capacitaciones, with varying themes of intervention, have persisted, at times benefitting from international funding, as provided by the SMI, which allowed health centers to equip midwives with basic material such as clamps, gloves, and soap (see Jordan in Yucatán 1989). In the 2000s, Mexico’s commitment to the MDGs translated into an increased focus on access to medical facilities. Trainings of traditional midwives focused on patient transfer; however, structural obstacles such as poverty, lack of infrastructure, and a punitive response to maternal mortality hindered the achievement of the MDGs (El Kotni 2018; Freyermuth 2015; Mills 2017). In 2009, the updated Mexican Health Law3 included the need for capacitaciones in order to “strengthen the technical competencies of traditional midwives,” institutionalizing a long-standing tradition of control over these women’s practices. With the Sustainable Development Goals, Mexico follows the global trend of training a new generation of technical midwives, however, in the country specific context of Mexico where traditional midwives largely outnumber technical midwives, the government’s insistence that these women’s practices (which are still perceived as dangerous) need to be controlled, explains why these trainings continue until the present day (Argüello-Avendaño and Mateo-González 2014). The current birth options in Mexico are not only limited to technical midwives or traditional midwives, but also include private birth centers training their own (foreign or Mexican) midwives, creating new birth options for (mostly) middle and upper class families (Dixon 2015; Sánchez Ramírez 2015). In Mexico’s rapidly growing competitive market of birth, there is still a need to circumscribe the practices of these potential competitors (Argüello-Avendaño and Mateo-González 2014; Vega 2016). Across the country, and within states, capacitaciones assume many forms and ranges of duration (El Kotni 2016; Ramírez Pérez 2016; Sánchez Ramírez et al. 2015). Their most common form is that of monthly workshops carried out in health centers either by the center staff or by nongovernmental organizations. The content also varies and the distribution of material depends on the health center or NGO organizing the training. In some districts, midwives receive a monthly stipend (like in the clinic managed by Dr. Andrés), while in others no funding is available and health personnel share some of their supplies with the midwives. Capacitaciones have shifted their focus from providing traditional midwives with biomedical knowledge that they are expected to apply in homebirths, to training them to detect danger signs during pregnancy, childbirth, and postpartum and to transfer patients to the state health care system at the opportune moment. The detection of high-risk patients is a key strategy of the Mexican government to diminish maternal mortality (Laureano-Eugenio et al. 2016), and midwives are instructed to check their patients for danger signs at every appointment, while training instructors insist on the early detection of symptoms that indicate high-risk cases. However, midwives are not the sole decision makers in such situations. Family members and their relationship with hospital personnel also weigh on the decision to transfer a patient (Berry 2010; Freyermuth 2003; Mills 2017), and the final decision can be in contradiction with the message of capacitaciones. 4 M. EL KOTNI Researchers’ critiques of capacitaciones have consistently focused on three major aspects: (1) the content of the capacitaciones, which set up Western obstetrics as the norm (Jordan 1989; Maupin 2008); (2) their format, which assumes that these women have formal schooling4 (Jordan 1989; Sánchez Ramírez et al. 2015); and (3) the dismissal of midwives’ local knowledge and practices, and the blaming of indigenous culture for maternal deaths (Cosminsky 2012, 2016; Murray de López 2015). The latter assumptions can have dramatic cultural and medical consequences, namely, the negation of indigenous therapeutic practices which have been shown to help prevent complications, such as ritual prayers for the good health of the mother and the child (Freyermuth 2003), the traditional abdominal massage, sobada, which can help reposition the baby, the knowledge of medicinal plants (Área de Mujeres y Parteras 2004; Ramírez Pérez 2016), and the use of the sweat lodge or temazcal which has medical and ritual uses (Groark 1997). Notably, traditional midwives have voiced their critiques of such training courses, which subordinate their knowledge to that of biomedical staff (Torri 2012) and blame them for maternal deaths. In addition to highlighting the persistence of these critiques despite the trainings’ changing forms, in this article, I analyze the resistance of politically organized midwives to the control over their practices. Reproductive governance and indigenous rights in Chiapas Historically, capacitaciones have acted as tools of reproductive governance (Morgan and Roberts 2012), by controlling poor women’s reproductive choices through the women who care for them – their midwives. Reproductive governance is developed from above, in the form of laws, policies, governmental programs, and from below, in daily interactions between women, medical personnel, state agents, and media discourse. The analysis of capacitaciones through a reproductive governance lens unveils the political strategies that give them life, the global directives, and the local interests that permeate them, but also mechanisms of resistance. In contemporary Mexico, capacitaciones are still part of a series of practices aiming at socializing indigenous women into the (biomedical) state health care system. For example, the cash-conditional transfer program Prospera (first implemented in 1997 under the name of Progresa) is built on a principle of “co-responsibility” of the beneficiaries (poor, often indigenous, women) who, in order to receive their monthly stipend, must engage in a series of practices. For women to comply with the maternal branch of the program, they must attend monthly talks at their health clinic (frequently focused on family planning) and, when pregnant, attend their local clinic for prenatal care (SmithOka 2013). Both capacitaciones and Prospera act to control poor women’s reproductive behaviors: during the monthly talks, Prospera beneficiaries are discouraged from giving birth at home with a traditional midwife; while during capacitaciones, midwives are encouraged to transfer their patients into the state health care system at the earliest sign of complication. For government workers and medical personnel, traditional midwives’ empirical knowledge is at best seen as helpful, but most of the time it is perceived as “largely obsolete and irrelevant to the outcome of birth” (Gálvez 2011:79). Today, in Mexico and Guatemala, capacitaciones are focused almost exclusively on detecting danger signs during pregnancy and birth, and traditional midwives are repeatedly encouraged to transfer their patients to state clinics at the earliest signs of anomaly (Cosminsky 2016; Maupin 2008; Torri 2012). In rural areas with no clinic, this message can discourage midwives from attending births at all (Vega 2016). Capacitaciones then shape poor women’s birthing options, and can severely impact their birth experience by exposing them to obstetric violence and discrimination, documented in Mexican maternity wards (GIRE 2015; Zacher Dixon 2015). The violence women experience in obstetric wards is one of the forms of discrimination poor and indigenous women face when interacting with state institutions. Indigenous women are particularly vulnerable to state violence (Sierra, Hernández Castillo, and Sieder 2013), linked to the historical construction of the Mexican state through the abuse of indigenous women’s bodies (Marcos 1992). Since the Zapatista uprising in Chiapas in 1994, human rights have provided a MEDICAL ANTHROPOLOGY 5 powerful framework for local NGOs and civil society to call attention to the marginalization of indigenous peoples in the country. Indigenous women in Chiapas have organized to demand cultural and gender rights, whether within the Zapatista communities (Speed, Hernández Castillo, and Stephen 2006) or within NGOs (Área de Mujeres y Parteras 2007; Daniels 2015). Behind the reference to “human rights” lie both the replication of a universalist discourse on rights and an attention to local practices and definitions of “human rights,” what Levitt and Merry coined “vernacularization” (2009). Variations in the definitions of women’s rights create tensions among biomedical practitioners, activists, and midwives. While the Mexican government frames women’s access to biomedical care as a human right (Gálvez 2011:77)—a discourse that implicitly positions midwives’ care as insufficient—technical midwives emphasize women’s right to choose their place of birth (Laako 2016) and traditional midwives insist that it is their cultural right to continue offering their services to women. Government workers’ insistence on women’s right to access hospital birth overlooks the violation of other aspects of women’s reproductive rights in public hospitals and clinics, a concern for Mexican NGOs (Grupo de Información en Reproducción Elegida 2015). Reproductive rights activists and technical midwives have criticized the medical view of reproductive rights, and challenged the definition of “women’s rights” as only a matter of access to health care (Laako 2016). Similarly, organizations working in the field of indigenous health have relied on human rights to reframe maternal deaths not as the consequence of traditional midwives’ care but as the outcome of state neglect, and a violation of “the economic, social, and cultural rights of the woman and her whole community”…

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