Institutionalized Violence Against Women in Mexican Hospitals

As a volunteer for Nueve Lunas, a Oaxacan non-profit with a midwifery school for indigenous youth, I have had the unique opportunity to attend several of their midwifery training workshops. At a recent midwifery workshop, I was tasked with interpreting for an American Obstetrician who had just moved to Oaxaca and wanted to help with the workshop. As we broke for lunch he spoke with one of the non-profit directors, explaining that he had been volunteering as an obstetrician in a public hospital in Oaxaca. He said that the Mexican obstetrician with whom he had worked would often sterilize women during cesarean sections, performing tubal ligations without their knowledge or consent, and without advising them afterwards. “But he didn’t charge them,” said the American. The Mexican obstetrician rationalized that he was doing this for the woman’s own good, supposedly because she had already had so many babies, because she would have consented had her husband not been there to pressure her not to agree to sterilization. Despite the fact that the obstetrician had not talked to these women and knew nothing about them, the American doctor seemed swayed by the Mexican obstetrician’s logic. Hearing these stories made me feel ill, but not surprised. I began researching the human and reproductive rights violations that took place in hospitals, and they seemed ubiquitous. It became overwhelmingly clear that women’s human and reproductive rights are systematically violated in hospitals throughout the Mexico on a daily basis.

I found numerous reports of forced sterilization in Mexico, especially upon poor and indigenous women. For example, beginning in 1998 numerous Indigenous Mexican women receiving services at an Omaha, Nebraska clinic learned that they had been sterilized or had an Intra-Uterine Device (IUDs) inserted without their knowledge while living in Mexico. Another report I found documented 200 cases of forced sterilization of women in the state of Puebla, between 1994 and 2000. In Veracruz there have been documented cases of women deceived into getting sterilizations, told that they would die if they had another child, or that they would receive a free operation to prevent cervical cancer, neither of which was true. Even the US State Department’s Bureau of Democracy, Human Rights and Labor acknowledges that there have been numerous complaints of forced sterilization of women in Mexico. The actual number of women who have been sterilized is impossible to tell, as it is grossly underreported.

These accounts of human and reproductive rights abuses by medical professionals highlight the institutionalized violence against women by the medical establishment. Medical professionals create an atmosphere of disrespect during hospital births, which make more grave violations of human rights possible, if not likely. Much like in an abusive intimate relationship, doctors use different tactics in order to maintain power and control in the doctor/patient relationship: emotional abuse, blaming, withholding information, making women marginalized throughout the birth process, coercing women to have IUDs implanted or be sterilization. A recent study details the violations of reproductive and human rights during hospital births in Cuernavaca. The article suggests the most hospital births “fall along a continuum of mistreatment or abuse.”
During these hospital births in Cuernavaca, the laboring women did not play the central role in the birth; the doctor did. Doctors controlled everything about the birth, and women were acted upon, having little agency in their own birth. Women were passive participants in their own labors, their sole function was to cooperate and help the physician. Women could then be blamed for a difficult labor for not “cooperating” sufficiently. Laboring women were threatened directly and indirectly, told that if they did not obey the doctor, they would face “serious consequences.”

When women complained of pain, their suffering was invalidated and ignored, or they were blamed and reprimanded for crying out during labor, told to “control themselves.” Women who continued to cry out or who disregarded doctors’ orders were ignored until they submitted to orders or shut up. Doctors frequently made inappropriate comments, implying that the pain of childbirth was a consequence of women having enjoyed sex, making statements such as: “But you enjoyed it before, didn’t you,” and “You wanted to, now put up with it.” When a doctor was asked if he would give a woman an episiotomy, he replied, “Of, course: to all of them, as punishment.”

Doctors and hospital personnel believed they possessed total knowledge regarding childbirth; therefore a woman’s statements about her own experiences were discounted. During childbirth, women were often given the bare minimum of information about their own birth, increasing their fear, and giving doctors more power. They were systematically denied access to their own medical files.

Nearly 40% of babies born in hospitals in Mexico are born by caesarean, giving Mexico one of the highest cesarean rates in the world. A study about cesarean sections in Mexico City explored obstetricians’ attitudes and treatment towards patients during childbirth. The high rate of cesareans can be attributed to the many benefits that the doctors gain, and to how much power doctors have over the childbirth. Doctors gain complete control over a birth, save time, earn more money, and gain more practice with the cesarean surgery. As one doctor explains, “It’s more of an effort for a gynecologist to wait for normal birth, which takes more time and more effort. For my own professional security, I operate without waiting for complications.” The wide reliance on cesareans also underlies the fundamental view that women are not capable of giving birth without a doctor’s medical interventions.

This same study found that obstetricians and hospital staff often coerced and intimidated women to consent to having surgical sterilizations performed during a cesarean, or to have IUDs inserted immediately following birth. Performing these procedures immediately after birth is not recommended by international medical guidelines. The high rate of sterilization during cesareans may be due to the fact that women undergoing cesareans received more pressure to be sterilized, since they were already cut open. For this reason, forced sterilization often takes place immediately following a cesarean. In some cases, if women did not want to be sterilized, physicians made them sign a waver saying that they refused to be sterilized, against the advice of the physician. Sterilization becomes the norm and women who do not want to be sterilized must actively refuse the procedure in the haze following a cesarean.

The attitudes and abuses found in these studies are by no means unique to Cuernavaca and Mexico City. For example, a recent survey of Oaxacan women of childbearing age about their experiences in hospitals found that 20% of the women interviewed complained that they had experienced verbal and emotional abuse in the hospital and 5% complained that they had experienced physical violence from hospital staff. While these abuses do not seem unique to a particular area of Mexico, they do seem to be more common in areas where women are more marginalized, poor, have lower levels of education, are indigenous, or speak limited Spanish. The institutionalization of violence against women in hospitals is far-spread, and deeply ingrained in medical institutions, whish are highly depend upon gender hierarchy, and are proponents of medical modernization, promoting the idea that more interventions in birth is better. Government officials and doctors alike buy into the developmental model of modernization, which views Western, highly technological medicine as the ultimate goal for all births, and views indigenous midwives as dangerous and archaic. So long as medical institutions invalidate women’s experiences and view women’s bodies as incapable, these sorts of human and reproductive rights violations in hospitals will likely continue.



Works Cited

Castro, Arachu, Heimburger, Angela and Langer, Ana ”Mexico City Cesareans, Working Paper on Latin America, Published by the David Rockefeller Center for Latin American Studies, Harvard University, 2000.

Castro, Roberto and Erviti, Joaquina “Violations of Reproductive Rights during Hospital Births in Mexico” Health and Human Rights, Vol 7. No. 1 (2003)

Mexico- Country Reports on Human Rights Practices, Released by the Bureau of Democracy Human Rights, and Labor. Unites States State Department, February 23, 2000.

Diebel, Linda “Mexico’s Indians Target of Sterilization Sweep” Toronto Star, March 26, 2003.

Informe Red DeSER, Violaciones a Derechos Sexuales y Reproductivos, 2000. Oaxaca.

Davis-Floyd, Robbie. “La Partera Profesional” Medical Anthropology (Vol 20, Nos. 2/3-4) December 2001.

Nueve Lunas Visits

During the Months of October and November, I (andrea) have visited most of the students at Nueve Lunas, the Midwifery school/training program where I have been volunteering. It has been a really inspiring experience and a lot of fun getting to know the future midwives and learning about the state of midwifery and women in their communities. In some communities there are still some active midwives, though most are getting older and have generally stopped practicing. In other communities there are long traditions of male midwives (parteros) , and that tradition continues at Nueve Lunas where 4 of the students are yound men. In other areas there aren´t any practicing midwives and most women now birth in hospitals or clinics. This is in sharp contrast to the previous generation of births. Almost all the students I visited had been born at home, and all of their parents had been born at home, most with the help of midwives. Federal welfare programs, such as Oportunidades, which is run by the doctors and nurses of local clinics, strongly discourages women from giving birth with a midwife, and punishes women by witholding money and services if they decide to give birth at home. Needless to say, it will be a challenge for all of the midwives-in-training to establish themselves in their communities and to gain the respect they so deserve.



Of course the midwives are not just health practitioners, they are also women´s rights activists and promoters in their communities. In talking to the students about issues affecting women, several stories/themes came up. Having worked on domestic violence in the US, I was interested to see how it was dealt with in Oaxaca. Unfortunately it is extremly prevalent, from some accounts, much more so than in the US. In most families, domestic violence is the norm rather than the exception. Impunity is also common. One student told me about a recent case in her town where a woman was murdered by her husband, who cut her up with a machete. He served a year in prison and was released. In most cases women´s only legal option is to make a formal complaint to the municipal agent or president. Should the authorities (mostly men) decide to take any action, it is often a light reprimand of the husband, who can defend his actions by saying he was drunk or his wife didn´t make dinner.



In another town, a woman sought help from the midwife in training, as her husband was trying to charge her with having an abortion. When the husband had learned of his wife´s pregnancy he had her pregnancy registered with the authorities. (I don´t understand what this means, or how he can make a matter of personal health public record.) She claims that she had a miscarriage at three months, (which occurs, unprovoked, in about 20% of known pregnancies, if not more frequently.) Her husband didn´t believe her and is trying to have her investigated for a provked abortion. At this point there is no proof either way whether it was provoked or not. The penalty for abortion is up to 8 years in prison.



In many rural areas of Mexico towns may govern themselves either by "Usos y Costumbres", by tradition and custom, using popular assembly, or by political parties. Most of the towns I visited were run by Usos y Costumbres. Perhaps the one downside of this method of rule is that the town determines who can and cannot participate in the popular assembly. In some communities only landowners may participate (mostly men), and in other communities women are completely banned from attending and participating in the popular assembly, nor can they be elected to any positions of power.


After feeling a little glum about the status of women in Oaxaca, I had the opportunity to attend another training workshop with Nueve Lunas, when was wonderful. We learned about obstetric emergencies, and reviwed positioning of the baby, etc.






Learning about fetal positions, we made paper pelvises to practice.




Students practice finding fetal position on each other.



How much blood is too much? Students learn what a normal about of blood looks like and what hemmoraging looks like.

Field Trip Pt 2: Los Ausentes

The field trip adventure from last blog entry continues...

That same day that I went to San Augustine Etla with the kids from our art workshop, we continued on to the studio/ranch of Oaxacan artist Alejandro Santiago, situated nearby.

He just finished this really amazing and huge project called 'Los Ausentes' (the absent), for which he built 2501 waist-high clay statues. Each statue represents a person from his home town Teococuilco (a small pueblo in the Sierra Norte area outside Oaxaca City) who has emigrated to the US. The statues are now on display in Monterrey.

He said that today Teococuilco is practically a ghost town; only elderly folks and a hand full of women and kids live there now, since almost all of the working-age men and their families have moved to the US or to bigger mexican cities like Mexico City, Puebla, or Oaxaca in search of work.

The emmigration situtation in Teococuilco is super-common. Alejandro said he could have done the same project about nearly any small town in Oaxaca, or most other Mexican states for that matter. Emmigration rates from Oaxaca state are exceptionally high though: Oaxaca is the poorest state in Mexico, and the fallout in the agricultural industry over the last few decades (largely attributed to free-trade agreements like NAFTA and competition from heavily-subsidized US corn) has devistated the area's corn-based economy.

Here's some photos!


The artist talking with students about the Ausentes project and emigration. Everyone in the group had close family and friends who had emigrated to the US.


Students looking at some of the emigrant statues that weren't included in the final piece.


One of the emigrants standing guard at the artist's ranch.


Students making their own mini-emigrants out of clay. These girls are sisters. One of them made an emigrant jumping over the border wall, and the other made an emigrant waiting on a bench for a coyote to sneak him over the border.

Field Trip! Pt 1: San Augustine Etla

Hey! Yesterday I (Tim) went on a Sunday field trip with the kiddies in the art class that I help teach. We (4 teachers and 30-some kids age 5 to 15) hopped on a bus to San Augustine Etla, a town up in the hills about a half hour outside of Oaxaca city. Fun!

First we headed to a little workshop that makes cool paper using local plants for fibers and dyes. Then we went to CASA, an old fabric factory that's been turned to a beautiful art school/gallery. I took a week-long class in poster design there last month and the posters we made are on exhibition in the gallery space. Here's what the day looked like...


Kids!


The 3 teachers.


The factory-turned-gallery.


Our posters on display.

These are the two posters i made for the course. The posters we made were illustrations for a kindof social-justice-themed ABC book that the teacher wrote. I got the letters K for Kiosko (gazebo in the town sqare, talking about the importance of public communal space, and I made a gazebo-head guy) and T de Tierra (earth, talking about environmental stuff, I made an earth sawing itself in half like lumber).

More kids, on crazy steps.

Midwifery In Mexico- Reflection on a Workshop

I recently attended a talk on midwifery (parteria) organized by Benito Juarez University during a week of women’s rights workshops. Nueve Lunas, an NGO dedicated to promoting and teaching parteria in Oaxaca, and where I am currently working as a volunteer, was asked to present on the topic. The director of the organization, a midwife (partera) herself, and one of the partera students from Nueve Lunas’ school came to discuss parteria with university students and other interested parties. After a half hour of figuring out which room we were supposed to be in, people started to trickle in. We sat in a circle and began with introductions explaining why we had decided to come to the talk and what questions we had about parteria. Having spent a fair about of time talking to parteras and generally being immersed in the partera world-view, I was shocked by several of the responses I heard.

The first woman to speak, a young doctor, explained that she was having a hard time getting women to lie down and stay on their backs with their legs in stirrups during labor and complained that women weren’t letting her check their cervix to see how dilated they were. She wanted to know why people weren’t coming to birth in the clinic like they should. Another woman, the coordinator of the event- who had earlier mentioned that she thought the subject was fascinating- said that she had recently attended a birth of a woman she didn’t know, where the birthing woman refused to lie down and insisted on pulling on a rope suspended from the ceiling while pushing. (A position that facilitates the pushing process because it engages the diaphragm while squatting). The woman telling us this was totally disgusted by the event and was further frustrated when the mother wouldn’t even let her film the birth. She kept repeating that she had found the birth totally ugly (“feo, muy feo”). Another woman explained that she found it irresponsible that a woman would go to a partera who was “supposedly” trained in attending births, when a clinic would have a team of obstetricians and pediatricians working as a team ready to dispense of high quality health care without any of the danger of home births. (Note- she has not had children or the misfortune of having to birth in a clinic.) The second woman agreed, reiterating that birth was dangerous and risky and should be practiced with obstetricians (literal meaning: to stand in front of) rather than parteras (literal meaning of midwife: to be with woman). I wondered why these women had come, what had they wanted to hear? A couple of other people said they were interested in reproductive health and wanted more information. I couldn’t believe what I was hearing! How did people come to believe that hospitals were less dangerous and more humane than birthing with parteras at home? To a large extent, racism and sexism are at the heart of this issue; traditional parteras are normally indigenous women and are stereotyped as superstitious and illiterate. During the 1960`s modern medicine sought to take birth out of the hands of indigenous women parteras and into the hands of white, male-dominated medicine. As late as the 1970`s traditional parteras attended 43% of Mexican births, dwindling to 17% in the mid 1990`s.

And it’s true that there is reason to be concerned about the risks associated with birth. Oaxaca has one of the highest maternal mortality rates in Mexico with 95 maternal deaths per 100,000 whereas the national average is 63.6 per 100,000. But are midwives really to blame for this? A recent study by the Centro de Investigaciones y Estudios Superiores en Antropología Social Pacífico Sur found that 44% of indigenous women who died during childbirth, gave birth alone or attended only by a family member. The study also found that 64% of women who died in childbirth had no prenatal care at all. The lack of prenatal care for pregnant indigenous women in rural areas is consistent with the decline in the number of midwives in rural areas, as midwives grow older and lack replacements.

The comments made during introductions reminded of the views surrounding birth in my own country, where approximately 1% of births are attended by midwives in home-births, whereas in Mexico home births are still somewhat common (17% of births attended by midwives in 1996.) though less and less so. In the US we have eliminated virtually all traces of traditional midwifery while Mexico still has a vibrant, though diminishing tradition of parteria. In the US, when I explained my plans to become a midwife, people ask “but isn’t home-birth dangerous?”

What does the birthing landscape look like in Oaxaca? Of the women who give birth in hospitals, most deliver by cesarean. The public hospitals’ cesarean rate is a whopping 65%; meanwhile the private hospitals are even worse, with an 80% cesarean rate. (The countrywide rate is 40% in Mexico-one of the highest in the world, 30% in the US. The WHO suggests 15% as a healthy norm.) Episiotomies (cutting of the vaginal opening to make more space for the baby to pass) are still regular practice in Mexican hospitals, despite the fact that it has not shown to help prevent fissures, only make them worse. Episiotomies are now long out of fashion for most hospital births in the US. In Mexico, women who give birth in public hospitals must give birth alone, aside from the constant interruptions from hospital staff, as fathers, and birth attendants are prohibited from being present during labor. In most cases women must birth on their backs (the least efficient and often most painful position), are hooked up to lots of beeping monitors[1], and are unable to move about freely or eat and drink anything. Unfortunately, much of these practices prevail in hospital births in the US as well.

During the talk we discussed common practices in hospitals and among parteras, getting at the fundamental differences between parteria and medicine. Parteras believe that women’s bodies work, know how to birth, that the women should be treated with respect and that the mother and baby are guiding the birth; parteras are there for assistance and intervention when necessary. Medicine seeks to fix a problem (in this case: birth) and doctors are taught to intervene to fix the problem- hence the 65-80% cesarean rate. Medicine has an important place in childbirth. That is to handle medical emergencies, not normal births.

After the talk we watched several videos, the first was a short Argentine video showing a typical birth in an Argentine clinic (very similar to a typical birth in a Mexican hospital or clinic.) We were watching a woman’s reproductive rights being violated. It was absolutely awful. The woman’s legs were tied to the stirrups, legs up above her head, gravity working against her. Multiple doctors stood by her vagina and right before the baby’s head appeared, an obstetrician got out his scissors and cut a large gash into her (episiotomy). Moment’s later the baby was born and immediately taken away before the mother got to see it. The baby was then poked, prodded, injected, washed, combed, measured, weighed- all before getting to meet its mother. It was awful to watch. (Watch ¨Callate y Puja¨on YouTube: http://www.youtube.com/verify_age?next_url=/watch%3Fv%3D8M9OA-oFka8

)The second video was of a Mexican patera’s birth at home in water. It couldn’t have been more different. It was calm and beautiful. While these two videos showed birth in its extremes, they demonstrate the essential difference between parteria and medicine: respect. I think the talk and videos had a pretty strong impact of the participants, and I believe that some of those women had a better understanding of parteria.

Sources:

La Partera Profesional : Articulating Identity and Cultural Space for a New Kind of Midwife in Mexico. Medical Anthropology, (Vol 20, Nos. 2/3-4) Dec 2001. By Robbie Davis Floyd

“Oaxaca: Muerte materna en municipios indígenas” by Pedro Matías, El Proceso 03/09/2007

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[1] studies have shown that these monitors only increase the amount of medical intervention, there is no benefit in terms of outcome for mother or baby

Random Parade, Random Lucha Libre Fight, Rah Rah!

Hey! A little while ago this random parade passed me on the street. These random parades and concerts in the middle of the day are super common here. I think it was a parade for like the 127th anniversary of the art school that i'm taking painting classes at. That calls for a PARADE! Complete with a band and big puppets and ladies with pineapples on their heads:

On a related note, Andrea and i recently stumbled apon this free lucha libre wrestling match in the square outside that same art school (we live on the big hill in the background where the huge mexican flag is. The flag's far larger than our house):

All clowns are scary but mexican clowns are the scariest!

A local artists' brilliant lucha libre-inspired artistic moral dilema (i don't know if you can see the detail, he's trying to decide between the virgin mary and bodyslamming a naked lady):

xo Tim

Arte Callejero

I'm sitting in what must be the most noisy internet cafe in all of oaxaca if not mexico if not the americas if not the world. To my left, there's a kid playing mario brothers with sound at full blast, behind me two girls sitting at two different computers listening to downloaded romantica music. They're all competing with eachother for soundspace, and the room's teeeeny. They keep inching up the volume on there speakers. This is getting RIDICULOUS!

Anyways, I wanted to post up some nice pictures of street art i've seen here in oaxaca. The fine art of painting street signs for busineses, concerts, lucha libre wrestling matches, and political campaigns is alive and well here. And these painters people really know their fonts, which is something i can get behind.

An ad/mural for a lucha libre match:

Wait the noise situation in this internet place just got even more ridiculous: The two girls are now listening to the SAME song, but they're at different parts in the song. It's Enrique Iglesias' new single. It's a sea of Enrique and it's at full blast!

There's also tons of silkscreened and woodblock prints wheatpasted up around the city and lots of spaypainted stencils and art,,, mostly politically charged stuff. I just got back from a workshop about silkscreen and stencil making with a good handful of these artists who are working in the realm of activist art.

XO-Tim