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MAGic2015: Anthropology and Global Health: interrogating theory, policy and practice

(P09)
Maternal precarity at the intersection of households and health systems: interrogating meanings of risk and power in maternal health
Location JUB-117
Date and Start Time 10 September, 2015 at 11:00
Sessions 3

Convenors

  • Maya Unnithan (University of Sussex) email
  • Almudena Mari Saez (Charite) email
  • Bregje de Kok (Queen Margaret University) email

Mail All Convenors

Discussant Jane Sandall (KCL)

Short Abstract

The panel explores the meaning of reproductive risk as a conceptual category and in terms of how it emerges and is articulated in household decision-making, perceived and performed in health worker practice and embedded in health policy discourse.

Long Abstract

The panel explores the meaning of reproductive risk as a conceptual category and in terms of how it emerges and is articulated in household decision-making, perceived and performed in health worker practice and embedded in health policy discourse.

With a specific focus on the relationship between risk and power, the panel invites papers which examine the following issues: What kinds of notions of risk are mobilised in the context of promoting maternal health? How are these framed, articulated, perceived and practised and what kinds of tensions arise in their deployment? What role do 'gender, social relationships and power play in the interpretation of maternal risk and in the functioning of health systems? What understandings of risk hide or reveal individual access and priority in care? In the context of labour, delivery and postpartum practices we ask how health practitioners navigate the tension between normal care and risk protocols to do with birth? What is the relationship between the 'management of risk' and the 'management of rights' (choice)? With regard to health systems, we seek to learn of the implications for understandings of risk and for maternal health in the aftermath of health crises such as Ebola, when care priorities shift.

This panel is closed to new paper proposals.

Papers

'Birthing outside the System' in the Netherlands: Preliminary findings of the WONDERstudy

Authors: Lianne Holten (VU university Amsterdam)  email
Esteriek de Miranda (Academic Medical Center Amsterdam)  email

Short Abstract

This paper will present the preliminary findings of research on the motivations of Dutch women to go against medical advice and protocol in choosing high risk homebirth, unassisted birth and cesarean delivery on maternal request.

Long Abstract

In 2013, lawsuits against three Dutch midwives spurred the discussion about women's freedom of choice in obstetric care and what to do if a woman chooses to birth 'outside the system'. In the Netherlands, there is a growing group of pregnant women that choose not to adhere to the rules of referral from primary to secondary obstetrical care. On the one hand, there are women with high risk pregnancies who insist on a homebirth. While on the other hand there are women who in the absence of medical indication demand hospital interventions as is the case with caesarean delivery on maternal request. There are also cases of women withdrawing from obstetric care altogether. It is estimated that each year approximately 200 women have planned unassisted homebirths.

To gain this insight into the motives of Dutch women to 'birth outside the system' and the experiences of the health care professionals involved in their care, the WONDERstudy (Why Women Want Other or No Delivery care) was initiated. This paper will present preliminary findings. Important themes arising from analysis of the first round of in-depth interviews are: resistance to the biomedical model of birth, a different risk perception and the impossibility of autonomous choice within the system. The women interviewed frequently perceived midwives not to be the expert on maternity care; for many intuition functioned as authoritative knowledge. Midwives were perceived as 'acting out of fear' and 'disturbing the birth process'. This may have important implications for (the improvement of)midwifery practice.

Of risks and complications, and interpreting the 'safety' of deliveries: multi-actors perceptions from rural communities in Malawi

Author: Isabelle Uny (Queen Margaret University)  email

Short Abstract

This paper explores the distinct conceptualisations of risk, complications, and’ safe’ deliveries by different actors in maternal health in Malawi, which shape the choice of ‘best’ delivery place. We discuss how tensions may arise between the expectations of, and satisfaction with, the care women receive in hard to reach rural areas.

Long Abstract

Globally, childbirth continues to be framed within a discourse of risks which can be best managed in facilities, by skilled attendants and through interventions, in order to reduce maternal mortality. Women's perception of risk -and choice of delivery place-is often influenced by their care providers, former experiences and by public information. In Malawi, where the maternal mortality ratio is high (510/100,000), the risk discourse equally pervades and the Government has prioritised skilled birth attendance and institutional deliveries. In 2007, it issued Community Guidelines preventing deliveries by Traditional Birth Attendants (TBA)- the non-formally trained, community providers of maternal care-, whom are publicly portrayed as insufficiently skilled, unsafe and often blamed for complications arising.

This presentation draws on findings from a larger qualitative study of the perceived effects of this new policy implementation, which uses a grounded theory methodology to analyse 65 interviews and focus groups conducted with a range of stakeholders in 2013 in Malawi. These findings explore:

• how risks and complications are conceptualised distinctively by skilled birth attendants, TBAs and the women they serve

• How those concepts are in turn mobilised to serve either the Safe Motherhood Initiative's goals; or for women to navigate the risky waters of 'safe' deliveries.

Drawing upon frameworks of authoritative knowledge and theories of quality of care (QoC), we develop a theory of what women perceive as 'good/best' delivery care, and how expectations and satisfaction of out-of-reach rural women, could be better met by interventions to improve the quality of delivery care in Malawi.

Risk and power in changing models of maternity care in Rwanda

Author: Frances Haste  email

Short Abstract

This study explores ways in which policies to reduce maternal mortality in Rwanda impacted on perceptions of risk and on behaviour, and how women and health workers negotiated biomedical and ‘traditional’ concepts within financial and organisational power relationships

Long Abstract

Rwanda reduced maternal mortality rates by two thirds in 10 years. This study explored how change occurred and how people made sense of it. Fieldwork was carried out with Health and community staff and local women in Western Rwanda. Government strategy was to increase services, community participation and uptake of health insurance, and to incentivise antenatal attendance and delivery in health centres. Punishment emerged as a key policy tool and a means by which health professionals exerted power; women were punished financially for home delivery and health staff displayed punishing attitudes to get people to use their services. These attitudes were resented by women and discouraged trust in staff and attendance at clinics. This is contrasted with empowering methods of a successful NGO-run maternity clinic. This punishment ethos combined with an increasing discourse of maternal risk and of modernity resulted in an increasing acceptance of using maternity delivery services. However, these co-existed with, and were often in conflict with, belief in magical causes of illness and use of traditional methods for protection against magic. High levels of mistrust extended to government such that health programmes, eg. contraception and HPV vaccination, intended to reduce risk, are seen as plots for further disempowerment and control. Themes of risk perception, empowerment and control are explored.

Risky people in risky environments: understanding notions of risk and birthplace in a First Nations community in Manitoba, Canada

Author: Rachel Olson (The Firelight Group)  email

Short Abstract

Critical examination of state opposition to the return of midwifery services in one community reveals how both people and their home environments are constructed as high risk and its implications for birthplace for Indigenous families in Manitoba, Canada.

Long Abstract

The risks and uncertainty associated with childbirth and how to best mitigate these are widely debated in both medical and public discourses of place of birth in Canada. In First Nation communities, these debates extend themselves into the role of the state and state policy as jurisdictional managers and decision makers of birth place for women and their families. This paper explores the issue of risk and birth place for First Nations families in Manitoba within the context of state-provided health care services in the community. It does so through looking at the conflict that arose from the re-introduction of midwifery services in one First Nation community, Norway House Cree Nation, in Northern Manitoba. While most women from Norway House experience maternal evacuation, which is the term used to describe the removal of women from their communities for birth, Norway House is in the process of returning birth to their community through the employment of a provincially funded Aboriginal midwife. This paper discusses the state opposition to the return of midwifery services back to the community and looks at the use of the concept of risk within this setting. One federal doctor opposed to midwifery services stated his reasons were that we were dealing with "high risk people in a high risk environment". Therefore, this paper explores how both people and environments are constructed as high risk, and how this effects the discussion around place of birth for First Nations.

Mala Leche: Interpretation of Risk and Medical Challenges to Exclusive Breastfeeding

Author: Jenna Murray de Lopez (The University of Manchester)  email

Short Abstract

This paper looks at women’s maternity narratives and beliefs concerning mother’s milk as a source of contamination for their baby. Resistance to doctors’ instructions to stop breastfeeding demonstrates how women interpret and measure risk against what it means to be a good mother.

Long Abstract

This paper looks at women's maternity narratives and beliefs concerning mother's milk as a source of contamination for their baby. During fieldwork in Chiapas, Mexico I came across repeated incidences where mother's milk or the mother's body itself was blamed for non-serious illness in a newborn. Despite public health messages promoting the benefits of exclusive breastfeeding women were repeatedly told by individual doctors that existing medical problems or complications in birth meant that their milk was causing harm to their baby. Physical and emotional conditions could literarily turn a woman's milk bad (mala leche). This reinforced a notion perpetuated throughout the clinical management of pregnancy and birth that without intervention a woman was at risk of harming her child. In Mexico women who go against advice are seen (by doctors and the state) to be increasing their risk of complications and in doing so they are considered bad mothers. Adhering to medical advice defines women as good mothers because they are demonstrating risk averse behaviour. The advice given to women to replace breastfeeding with formula does not take into account the logics of intercultural norms that breastmilk can be made good again by treating the mother with non-medical interventions. This leads to decision making in the home that goes against medical opinion. New mothers find themselves in an in-between space where interpretation of risk is dependent upon the importance of being a good mother in the eyes of the state or adhering to intercultural norms that a mother's milk is best.

Choice and purchase in Russian maternity houses: negotiations and domestification of risks

Author: Anna Temkina (European University at St.Petersburg )  email

Short Abstract

Discourse of anxiety and lack of trust to institutions characterize maternity care in Russia. Women make effort to create quasi-domestic relations within impersonal relations in hospitals. Personified and domestified relations are negotiated and paid for as a way of risk and "fate" management.

Long Abstract

Strategic organization of childbirth became an integral part of middle class life project in Russia. Demanding consumers evaluate options, make choices and pay for the service. Women report that childbirth should be controlled and not to be a "roulette wheel". Maternal houses (MHs) advertise paid and unpaid services; future mothers choose between free and paid options, and negotiate delivery conditions.

Why women prefer to pay for childbirth? They tell about anxiety, lack of trust to institutions, professional roles and impersonal relations in MHs. Woman want to avoid risks, to overcome the state of fear - threat to the lives of the mother and the child or health damage. They want to receive high quality of professional treatment and care, and to avoid "soviet" conditions (disregard, lack of privacy and comfort).

It is important for women to be "hold by hand" in labor; women make efforts to create quasi-domestic relations within MH. On the stake is non articulated gendered life of mother and child, women want to escape from health damage and death (perinatal loss, infant and mother's mortality); they pay for the sacral good. Both gender identity and life of two persons are at the stake. Personality and professionalism of obstetrician are considered to be crucial. Not state system, medical institution, nor science (with a low trust) guarantees success but concrete professionals, personified and domestified relations which are negotiated and paid for as a way of risk and "fate" management.

Risky Births in Southern Mexico. State Discourse, Women's Decisions and Indigenous Midwives' Resistance.

Author: Mounia El Kotni (University at Albany, SUNY)  email

Short Abstract

This paper explores discourses of risk in Chiapas. Using maternal mortality rates, the Mexican state presumes that birthing with a traditional midwife is unsafe. However, cases of obstetric violence create a counter-discourse, where for indigenous women hospitals are risky places to give birth.

Long Abstract

In Mexico, the State of Chiapas has one of the highest rates of maternal and infant deaths of the country (60.6 for 100,000 live births for a national rate of 42.3 in 2011). Following recommendations from the World Health Organization, Mexican policies push for the training of traditional midwives, which provides them with basic obstetrical knowledge and encourages them to refer their patients to hospitals. These trainings, conducted by government workers and medical doctors, are built on the premise that birthing at home with a traditional midwife is never safe, and that hospitals are the best place to give birth for all women - and poor, indigenous women in particular (Cominsky 2012, Smith-Oka 2013).

The Mexican state's particular construction of birth as a risky process, combined with monetary incentives to give birth in hospitals through conditional cash-transfer programs targeting poor women, constrain women's reproductive choices and disrupt Mayan women's birth practices. Birth is no longer a natural event where the woman is supported by her family, but becomes a risky practice performed by a technocrat, the obstetrician (Davis-Floyd 1992, Fordyce and Maraesa 2012).

In Chiapas, the discourse of risk has been used by indigenous women in a different way. The emerging discussion about obstetric violence in Mexico, and the heavy media coverage of cases of medical negligence in Chiapas, have provided indigenous women and midwives provide a counter-discourse of risk, in which going to the hospital becomes the riskiest way to give birth - alone and in a hostile environment.

Caesarian Sections in Argentina: Birthing and Obstetric Violence Risk in Configurations of Maternal Health

Author: Rebecca Martinez (University of Missouri)  email

Short Abstract

Obstetric violence is a recent term used to broadly describe dehumanizing treatment and abuse of medicalization in the birthing process. This paper explores global, national, and personal discourses of obstetric violence risk within the context of maternal and familial decision-making in Argentina.

Long Abstract

Obstetric violence legislation in Argentina reflects the fairly recent flurry of gender policies being implemented as a result of social mobilization around gender equity with new and established women's rights groups at the forefront. Obstetric violence refers to acts by which health personnel engage in dehumanizing treatment, abuse of medicalization, and pathologizing of the birthing process (Chiarotti, 2010). Argentina is only one of two Latin American countries to have implemented laws against obstetric violence: Venezuela in 2007 and Argentina in 2009. A central component of obstetric violence in Argentina includes extremely high Caesarian-Section rates there; it ranks seventh globally in unnecessary Caesarians (Gibbons et al., 2010). Through fieldwork conducted in 2014-15, I argue that the Argentine medical system has embraced and routinized this practice partly as a project of modernity, where medical intervention denotes technological progress in the management of otherwise unpredictable pregnant bodies. That it has become so familiar to some medical practitioners and pregnant women alike, has made the non-medicalized birth seem strange, archaic, and relegated to those who are not modern, White, middle-class subjects. These women in Argentina are most visible as Bolivian immigrants who are marginalized as racialized indigenous Others (e.g., "peasant," "ignorant," "poor"). Activists who have rallied to establish the obstetric violence legislation, however, are largely White middle/upper class women who, in their attempts to promote humanistic (non-medicalized) birth, are also prone to othering through discourses of risk and exoticism of indigenous women and their birthing practices.

Maternal Threats: Perceptions of Risk between Somali women and medical professionals in Nairobi

Author: Lucy Lowe (University of Edinburgh)  email

Short Abstract

This paper examines how a focus on multiple notions of ‘risk’ can illuminate the tensions of security, the state, and reproductive futures between pregnant Somali women and Kenyan medical professionals working in the Somali-dominated area of Nairobi.

Long Abstract

In the Somali-dominated Eastleigh estate in Nairobi, predominantly Kenyan medical professionals articulated a range of challenges in dealing with a population that was perceived as both 'risky' and 'at risk'. Fears of Islamic fundamentalism and an aggressive Somali Other were embedded in perceptions of a population constantly in flux. Perpetual flows of migrants with notoriously low rates of vaccination presented a continual risk to themselves and the host society. Somali women epitomised 'at risk' in reproduction: early and frequent pregnancies, widespread rejection of family planning, and refusal of antenatal care and many medical tests and interventions. At the same time, this Somali population, with a high demand for particular biomedical reproductive services, was a lucrative source of income for private Kenyan medical facilities. For Somali women, medical professionals presented their own risks, including exposure to the hostile Kenyan state, unnecessary medical procedures, and particularly expensive and reproductively damaging caesarean sections. Within the home, Somali women and their families - often straddled over countries and continents - negotiated desires for a particular understanding of 'safe' motherhood, with fears of the state and threatened fertility. This paper argues that interactions between pregnant, delivering, and postpartum Somali women and their medical carers highlight the ways in which trust and risk are perceived and navigated, and how these shape reproductive health decisions.

Water birth immersed in a "scientific" conundrum of "safety" and "risk": the case of Hospital de São Bernardo.

Authors: Susana Silva (University of Coimbra)  email
Joyce Camargo (Institute of Biomedical Sciences Abel Salazar, University of Porto )  email
Manuela Néné  email
Catarina Grande (ação da Universidade do Porto)  email

Short Abstract

This paper explores local narratives and social dynamics around water birth, from a retrospective standpoint in respect to a Portuguese public hospital. This hospital suspended water birth due to lack of evidence on the overall safety and risks involved.

Long Abstract

Water birth was a viable option in Portugal in one public hospital (Hospital de São Bernardo, in Setúbal) within the National Healthcare System, since 2009. Five years later, the Hospital's Administration Board decided to suspend water birth, with the support of the National Medical Association. "Lack of scientific evidence" was the motto. Navigating through the turbulent waters of international "scientific" recommendations on childbirth from the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics in the United States to the Royal College of Midwives and the Royal College of Obstetricians and Gynecologists in the United Kingdom, opinions on water birth differ. Some women from all over the country have chosen to deliver in Setúbal, defying some standardized practices such as delivering in their home´s nearest hospital and the lithotomy position, and, then, the overall "morally required routine" (Jordan 1978:2). Now, practitioners are telling them they did put "at risk" their selves and their babies. As anthropologists try to debate the very ontology of risk as a biomedical category shaping healthcare routines, maternal healthcare professionals aim to halter the effects of over-medicalized birth care, providing systematized data with scientific biomedical value. We thus collide in a "risky" terrain that we both want to improve. Within a public healthcare perspective, how should we ultimately address actual practices of risk management on maternal healthcare? This paper explores local narratives and social dynamics around water birth, from a retrospective standpoint, rather than ethnographic, in respect to Hospital de São Bernardo.

"She told me off as if I were her child": Maternal Ambiguities in the State Provision of Care of Cape Verdean Women in Portugal

Author: Elizabeth Challinor (CRIA/UM Centre for the Study of Social Anthropology, University of Minho)  email

Short Abstract

The paper examines the ways in which professionals in the social and health care sector in Portugal mobilize the concept of reproductive risk from a socio-economic rather than biological perspective, to encourage young Cape Verdean students to use contraceptives and in some cases to have abortions.

Long Abstract

The paper examines the ways in which professionals in the social and health care sector in Portugal mobilize the concept of reproductive risk from a socio-economic rather than biological perspective, to encourage young Cape Verdean students to use contraceptives and in some cases to have abortions. The paper questions the implications of professionals talking in the name of the state without suspending their personal values, focusing in particular on the role played by power and gender relations. The social and moral authority that professionals enjoy as a result of the expertise knowledge that they possess allows them to exercise unquestioned power in the health services they provide. The paper also argues that despite the widespread adoption of the concept of "gender" which draws attention to the characteristics and behaviours that different cultures and societies attribute to the sexes, its meaning in practice is often conflated with biological make-up and this is evident in the tendency of reproductive health services to adopt a narrow focus on "women". In the fuzzy field of practice (Bourdieu 1977) the concept of gender has failed to shift responsibilities from the body to the social. The patient is reduced to a fertile, pregnant body to be mastered by an individual "rational mind", failing to take into account that "being" is inseparable from "being with" (Sahlins 2011) and that responsibility is consequently plural.

This panel is closed to new paper proposals.