International Conference on Gendered Violence, University of Bristol, UK
by Jenna Murray de López, November 2011
If we hope to create a non-violent world where respect and kindness replace fear and hatred, we must begin with how we treat each other at the beginning of life. For that is where our deepest patterns are set. From these roots grow fear and alienation,—or love and trust. Suzanne Arms – A Handful of Hope (poem)
In 2010 the levels of caesarean section reached a global high in Mexico where they have now become only second to the surgical birth practices of Brasil. Along with other Latin American countries Mexico is committed to achieving the World Health Organisation (WHO) Millennium Development Goal (MDG) 5 which aims to reduce maternal mortality and achieve universal access to reproductive health care. This initiative has now entered its final stages with the MDG deadline being 2015, and this is represented in the activity on a national level towards implementing programmes and new welfare policies.
Increased access to institutions, particularly in urban areas has resulted in a figure of 93% of recorded live births taking place in hospital (WHO 2008). Under the philosophy of development this is taken as an indication that Mexican women are receiving assistance at birth. OECD indicators using data from 2007 estimate that 40% of all recorded live births in hospital are by caesarean section. Whilst this percentage does provide evidence of increased access to skilled birth attendants and antenatal care, the overall improvement of maternal mortality figures that health policy and practice has as its target fails to decrease at a rate anywhere near as significant. In this paper I aim to set the maternal mortality argument and policy smokescreen aside and view effective reproductive health in relation to a woman’s experience and her emotional and physical wellbeing, we can perhaps read the quantitative data in a much more alarming way than the current analysis suggest. An alternative reading, which also supports the need for more qualitative studies, shows that the 40% of pregnant women who enter a hospital are met by a birth attendant who will cut open her abdomen and uterus, while the remaining 60% who undergo a vaginal birth will have their perineum cut as part of routine episiotomy practice. This is done without aesthetic; and often either intervention is made without the woman’s direct consent.
Using obstetric violence in Mexico as a focus, this paper argues that the ways in which a society defines women and values them is reflected in the local treatment of birth. In this paper I attempt to use my research in Mexico to connect isolated works that have questioned gendered violence in hospital settings (Castro 1999: 209; Castro and Erviti 2003; Diniz and Chacham 2004; Kendall 2009) to the more recent quantitative work that analyses the rise in caesarean section (CS) in Latin American countries (Gonzalez-Perez, Vega-Lopez et al. 2001; Nazar A B, Salvatierra BI et al. 2007; Urquieta, Angeles et al. 2009; WHO 2009; Barber 2010). The voices of women, partners and medical professionals collected during periods (18 months 2007-2009 and 8 weeks 2011) spent in two urban locations in Chiapas, Mexico are also presented. Although recognised as a symptom of increased access to medical services, there has been little attention paid to the practice of unnecessary surgical interventions during pregnancy and birth in terms of acts of violence against women. Despite the development approach to public health aiming to empower women via financial control and equal access to services, the intention of neoliberal informed policy to control populations (Harvey 2005; Qadeer 2005) and individual bodies means that women continue to be subjected to physical, psychological and symbolic violence as part of daily gyno-obstetric practices in both private and public spaces.
- By physical violence I refer to the performance of unnecessary caesarean sections, episiotomies and surgical procedures related to birth control.
- By psychological violence I refer to the aforementioned actions and their affect on a woman’s bodily subjectivity.
- And by symbolic violence I refer to the way a woman is scarred by unnecessary surgical procedures and how this reflects an acceptance of violence towards female bodies in Mexican society as a whole. Within this symbolic violence is also a notion of class distinction in regards to the practice of classical incisions in public hospitals.
For reasons of simplification in terms of my discussion in this paper I will encompass all three definitions under an umbrella of Obstetric Violence.
Open-ended interviews were carried out with women and medical staff alongside observations in various environments, including antenatal classes, welfare programme platicas (obligatory information sessions), baby showers, other social events and gendered spaces. Initial analysis has identified three different circumstances that can result in caesarean section delivery which I identify as the following three categories: Legitimate; Systemic; and Elective. As the latter two denote I shall consider the nature of political economy and private healthcare however due to a distinct lack of data available in regards to Mexico and private health practices, Elective remains for the time being outside of the realms of this particular discussion. The disproportionate levels of caesarean section (CS) in Mexico have many complex political, social and economic causes that ultimately represent the violence in its society as a whole. This paper focuses particularly on the antecedents to disproportionate CS practice as being fostered and maintained within macro public health policy.
I wish to spend a few moments describing the Human Development Programme and health services in Mexico and then discuss the data relating to Chiapas. This region is chosen for its political, economic and social position in the country as a whole (Brentlinger, Javier Sánchez-Pérez et al. 2005; Secrateria de Salud 2007; Tinoco-Ojanguren, Glantz et al. 2008). There is not the time to go into much detail on the political economic situation in Mexico, so I will state briefly now that public health policy has as an economic model founded in the structural adjustment programmes and neoliberal reforms imposed since the mid 1980’s.
MDGs, Cash Transference Welfare and impact on behaviours
‘…many of the women that arrived [in labour] had to give birth in a hospital so that they could get benefits for the baby, they had to get a medical certifícate, it’s an important document they need in order to apply for Oportunidades’
Ricardo , 26yrs, Mestizo, Medic
“Many things have changed many people are going to hospital because of the Oportunidades programme. They have to go to be seen or they will take their money from them…That’s why the midwives don’t practice the same, they have no business…”
(Carlos, Rural Community Health Promoter , 38yrs, Chol, 9 children all home birth attended by traditional midwife)
In both developed and developing countries for many decades, the search to improve maternal health and birth outcomes has led to an almost complete medicalisation of pregnancy and birth based on a dominant interventionist model (Barber 2010). I have found that in existing literature and in my own qualitative data I am met with a wall of policy that legitimates the appropriation of birth experience from thousands of women and acts as the catalyst for violence of varying kinds. In text analysis from women in both social and private spaces, and with health professionals the theme of access to welfare is a constant. It appears to affect every aspect of the pregnancy and birth outcome and illustrates the complexities of a pregnant body in a political economic world. The pregnant body is in a state of flux, it is neither a solitary life nor two lives, it is at every stage a social product. It is important to consider the contribution of macro health policy and micro gyno-obstetric practices in local, cultural systems. The creation of universal medical norms in order to deal with the global management of populations produces mechanisms by which political economic forces impinge on the body. Foucault wrote ‘In a sense, the power of normalisation imposes homogeneity, but it individualises by making it possible to measure gaps’(1977) . In other words in measuring the normal, an abnormal is identified. Pregnant women must fit into measurable categories that are defined by medical discourse and aimed at efficiency. If they do not respond well they are become deviants to a system and can be manipulated to conform. When one thinks in terms of a universal public health policy and medical practice this is likely to have profound effects on those accessing health services on local levels in any cultural context.
Oportunidades (previously known as PROGRESA) is a conditional cash transfer program that started in rural areas in 1997. Its aim is to improve the education, health, nutrition, and living conditions of population groups in extreme poverty and to break the intergenerational cycle of poverty. In the area of health, the programme offers an essential health care package that includes pregnancy and delivery care for women enrolled in the program. In the case of delivery attendance, health institutions are responsible for providing delivery attendance in their facilities. Attendance at the health promotion talks and medical checkups are a requirement for being registered on the programme and receiving financial benefits. The coercive nature of cash transference programmes impact dramatically in terms of behavioural and cultural change. Although they propagate a firm belief in empowering women by recognising them as responsible financial heads of the household – any financial benefits are given directly to the women. The Oportunidades programme with its strict compliance to medical attention and training programmes and its payments in terms of vouchers does not translate to women gaining some sort of independence or financial control over their lives. In line with the critique of neoliberal welfare policy, the Oportunidades programme reinforces the notion of women’s independence on a patriarchal state and their status as passive and docile agents. This use of coercive welfare programmes results in a continuing cycle that legitimates control of women’s bodies, affecting their social and economic productivity in a negative way that ultimately increases further their dependence on the patriarchal state.
Chiapas as a case in point
An explorative investigation into medical attention in childbirth affecting indigenous migrants to urban areas of Chiapas was carried out in 2007 (by Nazar et al). This study also makes comparison with mestiza women living in areas of social exclusion who are likely to be using the same health services. In the period of the study, alongside an increase in births attended by institutional medics, a decent in the frequency of vaginal births was registered in both the mestiza and indigenous population. Nazar et al state that in these two cities in Chiapas alone from the period 1979 – 2003 the practice of caesarean section has increased almost nine times (870.0%) in the mestiza population and almost four times (394.1%) in the indigenous population.
Chiapas has been heavily targeted by the Oportunidades programme due to its socio-economic status and large rural populations and this has had a direct impact on cultural practices, traditional midwifery and woman centred health care. Participation in educational platicas promote a woman’s responsibility to her gestating foetus and newborn, but they do not discuss the right of a woman to birth where and with who she most feels comfortable with.
“I had a good pregnancy, no cravings, no tiredness, no problems you could hardly tell I was pregnant. I was tiny…I worked and studied up until the baby was born…I felt very healthy”
(Rosie, 25yrs, Tzeltal, Birth Outcome: CS Public Hospital)
‘…first they take you to a place to try a normal birth, but if the [umbilical] cord is wrapped around the baby’s neck they have to do a c-section’
(Bety, 40yrs, Tzeltal, Birth Outcome: CS Public Hospital)
‘…for example if they arrived around 2 or 3 in the morning in labour, and if they were a primagravida ….if it was 2 or 3 in the morning, the gyno-obstetrician would say “lets operate”, he would say that because we wanted to sleep, we had to wake up [in the morning]’
Ricardo , 26yrs, Mestizo Newly Qualified Medic
Anthropologist Bridgette Jordan wrote that the power of authoritative knowledge is not that it is correct but that it counts (Jordan 1993:154). The consultant room and labour ward provide a space for intra-cultural practices and violent tendencies resident in the wider Mexican society. Medical practices and education are from European/American allopathic model of medicine. A model of medicine that not only pathologizes pregnancy and birth but that is often outmoded in the very place it was originated (Jordan 1993:185). The objective of reproductive health and clinical services on a local level place an emphasis on the early detection of complications through the use of technology. A technopolitical economy in obstetrics has specific consequences for women and their bodies throughout pregnancy and beyond. The technological model of birth encompasses notions that a woman’s subjective bodily knowledge has been disproved, and therefore displaced by technology as producer of authoritative knowledge (Davis-Floyd 1987; Davis-Floyd 2001). This means for instance that the skilled birth attendant will interpret a pregnancy, labour and birth process via technology as dominant over anything the woman may say she feels. Yet, in the medical space at the same time that medical knowledge dominates actors are embodied by their own historical, cultural and gendered knowledge upon which they also use as a basis for assumptions and decision making. It is at this point where it is possible to indentify the social attitudes towards women based on gender, ethnicity and social class and how they are reflected in medical practices. The reasons stated by healthcare professionals for performing CS, CS with a classical vertical incision, episiotomies, tubal ligation and internal examinations during contractions, though they are legitimised through medical discourse are rooted in cultural and gendered attitudes to women and women’s bodies. The more subtle forms of coercion that take place, as documented in my own research as well as existing literature are harder to explain or mask with medicalized language. Women whom I spoke to who had experienced antenatal care provided by either State or Private healthcare had been offered a CS from the first trimester of pregnancy, many were also challenged by medical actors if they expressed a preference for a normal birth. Forms of resistance to undergoing ultrasounds, taking medication or vaccines or insisting on low interventionist methods are met with subtle threats of mortality in relation to mother or baby. I certainly do not wish to argue that this form of violation if specific only to Mexican medical models of pregnancy, but qualitative analysis does demonstrate that certain violations may persist more than others due to the fact that women’s responses are informed by their status in the wider society – in which in many arenas politically and economically is generalised as subservient and suffering. The data provided by women and health professionals in terms of antenatal care suggests that CS as a birth outcome is built into the apparatus of the healthcare system long before the women enters into her third trimester. Offering the counterargument that current reproductive health programmes and practices are likely to increase the chance of a CS being performed brings about many questions as to how this in any way is beneficial for the overall health and wellbeing of women. It is generally accepted by the WHO that an increased level of CS equates to better access to medical services and when medically legitimate, an improvement for maternal and infant mortality. Perhaps an equal focus should be placed on interpreting what is meant by an almost 10 fold increase in CS in terms of quality of life for women. The aim of policy and development programmes is to improve life expectations for both women and babies, but the lack of distinction in regards to the quality of treatment and recognition of the woman’s experience has serious consequences in regards to local practices and dominant medical discourse.
The call for papers for this conference stated that “Violence committed to establish to maintain power relations between genders continues to be a major global health problem” – the normalised violent practices that many women are subjected to in pregnancy and childbirth translates to a situation where universal attempts to improve health are actually part of the problem.
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 In Mexico the OECD base their estimation on public hospital records and data obtained in the National Health Surveys. Estimation is required to correct for under-reporting of c-section deliveries in private facilities source: http://www.oecd-ilibrary.org accessed 29/10/2011.
 First time mother