Rumors, Threats and C-sections in Rural Yucatan
One fall evening in 2013, sitting on a bench in front of her house, I talked with Elena about her life, work and some of the pressing health concerns of the residents from her rural pueblo. Elena is a registered Yucatec Maya midwife living and working in Saban, Quintana Roo. Her knowledge highlights the cultural significance of rumor in local women’s encounters with biomedicine and the state. An analysis of rumors and threats is helpful for understanding the different power dynamics between rural Yucatec Maya women and state health workers, particularly because each group counters the narratives and practices of the other through techniques that represent their social position and authority. After about half an hour of conversing, in a lowered voice, Elena told me about events that transpired earlier that day.
Elena started her story by speaking about a middle-aged mother at the end of her pregnancy, who I call Amalia. The local clinic doctor had labeled Amalia “high risk” and told her to go to the hospital for the delivery of her child. Amalia had been avoiding the doctor for over a week — hiding in her house every time the physician came by. Amalia had attended all her prenatal checkups at the local clinic and understood the doctor’s concerns, yet based upon her positive past experiences with midwifery care and fear of mistreatment from hospital staff, she chose to defy the doctor’s recommendation. Amalia believed she could safely give birth at home with the assistance of a midwife.
Elena explained how earlier that day, the doctor gathered all the local midwives and warned them of Amalia’s dangerous condition and tried to persuade them to not attend to her. She ended the meeting by telling the midwives that if the mother died at home it would be the attending midwife’s fault. The doctor’s desperation to change Amalia’s mind, Elena told me, was motivated in part by the need to absolve herself from the responsibility of the situation, because doctors are held accountable by their superiors for the overall health of the entire community. Later that same day, Elena continued, the doctor’s supervisors came to the community looking for Amalia. After forcing her out of her home they tried to convince her to come with them to the hospital. Amalia held her ground and refused. The doctor and her supervisors agreed to leave Amalia only after she signed a legal document acknowledging her dangerous medical condition and decision to disregard the advice of medical experts. Amalia was pressured to verbally and legally acknowledge that she purposely chose to put her own life and that of her unborn child at risk, in defiance of state-backed biomedical expertise and care.
This story illustrates some of the coercive ways in which childbirth is understood and practiced in rural Yucatan. In a community were midwives are the only accessible and dependable health care providers, hospitals and their biomedical staff are often viewed with fear and mistrust. This suspicion of biomedical providers is extended to local community clinic physicians who use scare tactics to change women’s behaviors.
As anthropological scholarship has shown, rumors are often mobilized as weapons of the weak, marginal, and subaltern. In rural Yucatec Maya communities, women young and old agree that the probability of coming home after a hospital birth with a cesarean section (C-section) is incredibly high. Women refer to the procedure as “being cut.” It implies a violence that is done onto their bodies by state sponsored biomedical practitioners. Women explain that doctors are quick to resort to “cutting” a woman because they are impatient and often unwilling or too unskilled to work with a mother through a complicated delivery.
Yucatec Maya women use rumors to talk about C-sections and hospital births in order to criticize the abuse and violence they experience by hospital staff. Through rumors, women challenge the Mexican biomedical community’s overuse of C-sections and ultimately their disregard for the lives and experiences of poor indigenous women. Although some stories might be exaggerated, overemphasized, and speculative there is a certain level of truth to what is said and ultimately believed. For those who have not experienced a C-section, the encounter is not far away — it is present in their close-knit social and familial circles. Every woman in the community personally knows at least one person who has had a C-section. In fact, the overuse of C-sections is a pressing problem throughout Mexico. A 2010 World Health Organization report lists Mexico’s C-section rate at 37.8%, more than double their worldwide justified cesarean range of 10-15%. For many women, the high rate of C-sections represents the lack of value the state and biomedicine place on the bodies of poor indigenous women. The overuse of C-sections demonstrates how the culture of biomedicine in Mexico has disregarded or underplayed the consequences its practices have on the lives of women — C-sections are an invasive, painful surgery with a lengthy recovery period. Many women poignantly ask, “who will take care of me and my family if they cut me?”
Under state pressure to lower maternal and infant mortality statistics, local physicians and regional health workers have resorted to scare tactics to compel women to abandon midwifery for a hospital birth. Threats have become a popular mechanism of persuasion, backed by the power of the Mexican government. Women are threatened with the safety and life of their child. If the hospital doctor considers a woman’s labor complicated or failing to progress, she is told that her unborn child will die unless a C-section is performed. Women are also told that all “good” mothers should choose to give birth in the “safest” place, the hospital where they are surrounded by professionals and the advanced technology needed to save their life and that of their unborn child if complications arise.
As Elena’s story about Amalia brings into sharp relief, local midwives are also intimidated with threats of severe punishment (such as the possibility of imprisonment) if they attend “high risk” mothers. Doctors and regional health care professionals claim that midwives support women’s decision to defy their authority. Yet, midwives are often left in a bind. They understand the dangerous complications that can arise during “high risk” labors, but they also know that some women will refuse to go to the hospital regardless of what anyone says. Yucatec Maya midwives share some of the same ethics as biomedical practitioners — they too have a responsibility to help people in need. Midwives know that if they refuse to attend women who go against state medical advice and stay home, these women will be left alone to handle a possibly dangerous situation. Morally, midwives cannot let this happen. Their only hope is that the labor will progress without serious complications, and if they do arise the mother and/or her family will be open to listening to the midwife’s advice to go to the hospital.
Interestingly, if not ironically, threats are also used against local biomedical practitioners. Their work is judged on the overall health statistics of the communities they are assigned to. If a mother or infant dies during childbirth, the local physician is also blamed. This in no way excuses the tactics they use, but it does speak to the broader power dynamics at play.
Discussion and Recommendations
Cultural traditions, positive past experiences and comfort are primary motivators that encourage rural Yucatec Maya women to stay home and give birth with a midwife. But rumors of abuse and the widespread sharing of their painful experiences during hospital births are also significant contributing factors. However, women also understand the limitations of midwifery and acknowledge the specialization of doctors and biomedical care. Most women have said they want to labor at home but if complications occur they expect their families to quickly transport them to the hospital. They know if they encounter a serious complication during pregnancy and/or childbirth, the hospital is the place to go. The critical insight is that for them biomedicine is primarily seen as a safety net when midwifery care can no longer help the mother. Women also clearly understand the consequences of their decisions and are aware that as soon as they walk into a hospital they are subject to the rules, procedures and demands of the medical staff. They acknowledge that seeking treatment in a hospital requires them to surrender their bodies to state biomedical workers and that as a result they might lose their ability to question medical staff and speak up for themselves.
Reducing maternal and infant mortality should continue to be at the forefront of Mexico’s health policies and development projects. Yet, threatening local women and midwives with scare tactics is not a viable solution. Based upon my research, I have four recommendations to help encourage “high risk” Yucatec Maya women to seek hospital care. First, state hospitals need to actively work to lower their cesarean rates and prioritize international standards for safe and mother/infant-friendly hospitals. Second, hospital staff and local community doctors need to acknowledge the concerns and fears of rural Maya women and recognize that they are valid and come from the shared knowledge of women’s previous experiences. Third, once women arrive at the hospital, they must be treated with respect and allowed to be active participants in their own labor and delivery. Finally, state health care policy makers and health care professionals need to continue to foster collaborative relationships with local midwives that include a commitment to continued training, partnership and respect.
Veronica Miranda is a doctoral candidate in medical anthropology at U Kentucky. Her dissertation research focuses on how rural Yucatec Maya women, midwives, and state health care workers participate in the production of childbirth practices in relation to federal health policies and programs.