Maternity Care, Sovereignty and Governance in Guatemala

During fieldwork in 2010 on maternal healthcare in rural Guatemala, I was struck by the focus that local health workers placed on planning for obstetrical emergencies. At regular training sessions, they demonstrated to local birth attendants how to identify a risky pregnancy, refer a woman to a doctor in the event of an emergency, and use a brightly-colored poster—called a Plan de Emergencia (Emergency Plan)—to help plan for obstetrical emergencies. In this piece, I consider the linkages between planning for obstetrical emergencies in rural Guatemala and contemporary forms of governance. I ask: why are obstetrical emergencies the focus of considerable planning, preparation and education in rural Guatemala today? To what end?

Planning for Obstetrical Emergencies

Health center (Centro de Salud), where many referrals for obstetrical emergencies are received. August 2010. Photo courtesy Elizabeth Hallowell

The Emergency Plan poster is meant to help birth attendants didactically, as they teach pregnant women how to prepare for birth and possible complications. The idea is that birth attendants will use the poster to make a plan with an expectant mother to get her to a health center or hospital, should one of them observe a danger sign, like vaginal hemorrhaging or severe headache. The boxes on the poster show the steps an expectant mother ought to take in order to plan for a birth, such as deciding what health post or hospital she will go to for care, and figuring out how much cash she will need to keep on hand to pay for emergency expenses. Many birth attendants reported making emergency plans with their patients or referring them to a medical facility when necessary. As one birth attendant, Maria (a pseudonym) told me, there are committees in each neighborhood that can orar—pray—for money to cover both the typical expenses of engaging the formal healthcare system in Guatemala (such as having to pay for your own medical supplies) and expenses that could be incurred in the event of an obstetrical emergency (like the cost of gas for an ambulance). And, as Dr Tax (also a pseudonym), the head of the health center explained, failing to make these plans can render a birth attendant vulnerable to legal liability. If a woman dies from pregnancy-related causes and the attendant has not made an Emergency Plan with her, that failure can be used as evidence of negligent practice. In extreme cases, an attendant can lose her license.

One thing that I found striking about these posters and the plans that formed around them was that the aim was always to get the woman to a doctor as quickly as possible. Yet, health workers and anthropologists alike have identified a number of factors that can make going to one of the region’s emergency facilities incredibly difficult. For example, as birth attendants and nurses emphasized during my fieldwork, many families do not have the cash on hand to pay for emergency transport, while the emergency facilities themselves may not be fully stocked when the pregnant woman arrives. Scholars of birth and biomedicine in Guatemala have also identified other factors that can complicate the provision of emergency obstetrical care. For example, patients, especially indigenous patients, expect and often experience poor treatment in the national health system; transportation to these services can be long and dangerous, in addition to being expensive; and local conceptions of the good birth (that is, a homebirth with specific family members and a birth attendant present) may clash with biomedical conceptions of the safe birth (that is, a hospital birth supervised by a doctor) (NS Berry, Unsafe Motherhood, 2010).

Caring through Planning

Despite these concerns, emergency planning continues to be one form that local maternal healthcare takes—often through care providers’ heartfelt work and genuine investment in the larger goal of preventing pregnancy-related death. Indeed, many of the birth attendants I spoke with expressed a desire to attend trainings and get better at looking for danger signs. Concepción (a pseudonym), a long-time birth attendant, told me that she liked the trainings because they gave her an opportunity to learn, especially about the many risk factors that women face during pregnancy. Maria explained that being well-trained was important for a birth attendant’s practice, and that she routinely used the Emergency Plan poster with her prenatal patients. Health center staff tasked with carrying out the trainings also expressed the importance of training birth attendants and looking for danger signs. Elena (also a pseudonym), one of the nurses responsible for administering the trainings, explained in an interview that these trainings are an important part of lowering the maternal mortality rate. She felt embarrassed that the health center could not provide better training conditions, since it lacked the resources to do so. For Elena, the national health system continually pushed the health center to “capacita, capacita, capacita”—train, train, train—but without providing them adequate materials or money to do so. She described feeling caught between “la pared y la espada”—the wall and the sword—to train attendants to do this important work, but without the material support she needed. What I found striking throughout these conversations was that even as some care providers (like the birth attendants) were rendered juridically vulnerable by the logic of this public health intervention, and others (like the nurses) were caught between “the wall and the sword,” many of them seemed to genuinely care about planning—and planning well—for obstetrical emergencies.

Planning as Governance

Building on Nicole Berry’s insight that such plans ask (indigenous) pregnant women to fundamentally rethink their understandings of the role of biology, the family and the self in pregnancy and birth (2010:192), I suggest that by looking closely at the Emergency Plan and the public health imaginary of which it is a part, we can see specific modes of reckoning temporality and sociality in maternity care today. This is to say that what we see is an attempt to manage risk factors that might appear, and to posit one course of action as most likely, even inevitable, once a risk factor is observed. Social relationships are rearranged or newly constituted, as with the committees that help families with emergency expenses, while responsibility for anticipating and handling risk factors is allocated primarily to birth attendants, nurses, and families. Most importantly, “good healthcare” is redefined to include emergency planning. Here, making plans, making them well, and especially getting a woman to a doctor, are cast as imperative aspects of “good” caregiving. I argue that what we see is thus the power to shape “tense and event” (E Povinelli Economies of Abandonment, 2011): what might happen, who ought to do what, and how maternity care is likely to (even inevitably going to) unfold.

The Guatemala case shows us that managing “tense and event” is part of managing reproduction—that is to say, of “reproductive governance”—in the Americas today (L Morgan and EFS Roberts “Rights and Reproduction in Latin America,” Anthropology News 50[3]:12, 16). In Morgan and Roberts’ formulation, reproductive governance refers to the contemporary neoliberal, market-oriented, and rights-based discourses that frame reproduction in contemporary Latin America. In this analytical grid, for example, women are framed as consumers of fertility services and fetuses are framed as the subjects of rights. I suggest that the Emergency Plan and emergency planning are also key elements in this grid. Planning in this way is a tool not only for biomedically managing a woman’s laboring body—for getting her to a doctor, whatever the cost—but also for managing the socialities and temporalities of caregiving amid shifting modes of reproductive governance.

Elizabeth Hallowell is a PhD candidate in cultural and medical anthropology at the University of Pennsylvania. Her dissertation research examines the interplay of biomedical, regulatory and individual understandings of pregnancy-related emergencies in the US. An extended version of this piece explores power and emergency in maternal healthcare, is forthcoming.