Examining Boundaries in Adolescent Birth in Mexico
Adolescents as reproducers are often considered a problematic category because of their paradoxical duality as children who have babies. For women outside of the margins, whether economically or socially, becoming a mother is fraught with many layers of meaning. Teenagers as a category are not usually considered to be marginal or outside boundaries, but when they become producers of new life, their status shifts into one of risk. Clinicians in Mexico attending to adolescent women in childbirth often enact these perceptions of risk through forms of obstetric violence, characterized by dehumanizing and unnecessarily interventionist treatment, exacerbating lack of dignity for obstetric patients. Here I consider the ways that subtle forms of obstetric violence are entwined within physical and social boundaries in the birth experiences of adolescent women in a maternity ward of a public hospital in Puebla, Mexico.
Puebla is a medium-sized city of about two million people in central Mexico. It has a rich history that weaves colonial struggles with indigenous marginalization. This is reflected in the marked stratification between the wealthy and the impoverished populations. The latter, usually working in the informal sector, rarely have access to private health care, and rely on the welfare of the state embodied in public hospitals and clinics. The hospital where I did this research served some of the most marginalized populations in the city, attending to about 9,000 births a year. It was a high stress environment for both clinicians and patients, regularly functioning at 140 percent capacity. Space was at a premium. Patients were moved through the ward as rapidly as possible to make space for new cases. This concern with speed often created situations of obstetric violence, as evidenced by the 45 percent cesarean rate and the high number of obstetric interventions (episiotomies, Pitocin, etc.). About 25 percent of the ward’s patients were adolescents.
As I observed in the maternity ward over the course of three months in 2008 and 2011, space was in very high demand. Thus, boundaries served many functions within the hospital environment. They were divisive, stratifying the desired reproducers from the undesired; they were physical, controlling movement of patients within hospitals; or they were sometimes fluid, negotiated by the very people they were meant to define and contain.
Because a quarter of the births were by adolescents, ranging from 12–19-year-olds, the hospital designated its psychology department as a task force to tackle this issue. Efforts were made to address issues of family planning, domestic violence, infant early stimulation and prenatal care. Adolescents were targeted in the hospital waiting rooms and provided with talks and information about sexuality and reproduction. If an adolescent declined the information, she would be placed on a list to be more personally targeted at her hospital bed, so she could leave the hospital with information about reproductive and sexual health.
Despite the well-meaning efforts to educate adolescents about their health, much of the language of clinicians verbally separated the women who should reproduce from those who should not. Many clinicians questioned the intelligence of the patients, wondering why the young women did not reproduce in ways that, at least to the clinicians, made sense. Many were also concerned with single mothers, highlighting their marital status as a social problem that would eventually cause harm to the patient’s child. This was evident in the interactions between one resident and her patient, when the latter refused contraception. The resident voiced her displeasure, stating “She will not look after herself. Only 17 and already one birth and one miscarriage.”
The recurring theme in the ward was cooperation, defined not only as working together for mutual benefit, but also being compliant with clinicians’ orders. This is illustrated by the words of one female physician “Single mother and she won’t cooperate. She’s been this way since her arrival. She doesn’t want to help [us]. That is what they’re like.” Cooperation additionally had a broader social definition of compliance with society’s expectations. Thus, most adolescent patients were a priori non-cooperative, as they had already reproduced outside of social boundaries. The physicians established a very clear boundary between themselves and the patients to whom they attended. It was evident that the female physicians and their patients lived in a system of stratified reproduction, which Shellee Colen defines as a discrepancy in policies and approaches that support the reproductive practices of one group while preventing that of another group (Colen, Shellee. 1995. “Like a Mother to Them.” In Conceiving the New World Order. Pp. 78–102. University of California Press).
A significant part of being a hospital patient is ceding one’s body to others’ control. In Puebla, physical boundaries controlled and confined the movement of patients from one location to the next. There were several structures that created physical boundaries that confined women’s bodies, such as labor cubicles, gurneys, or doorways. Certain boundaries were related to the stage a pregnant patient was in—the emergency room in early labor, the labor and delivery ward in active labor, and a delivery room during birth.
Some boundaries that served to constrict movement by confining women to one location would usually not be considered boundaries at all, for example, the intravenous drips. Because all patients would be connected to a drip, their movement was completely curtailed, and they were confined to the gurneys on which they lay until someone wheeled them to another location. The philosopher Reviel Netz argues in his book Barbed Wire that by understanding the things that create boundaries we can then understand how motion is facilitated as well as prevented.
One boundary that had particular importance in the birthing process at this hospital was the Plexiglas boundary between the emergency room and labor and delivery. It was a physical boundary between both wards that necessitated patients to move from a wheelchair in the emergency room to a gurney and then slide across the boundary to a gurney waiting in the labor and delivery ward. For the women in labor, already heavy from pregnancy, this was a very cumbersome process. The Plexiglass clearly divided the natural progression of birth into different stages, necessitating the authority of clinicians to determine when and how a patient could enter.
Once patients entered through this boundary they would only be able to emerge at the discretion of clinicians, as one young adolescent mother discovered. Due to several logistical and bureaucratic mix-ups she was placed in the incorrect ward and, despite her increasing contractions, was ignored for many hours until her husband managed to threaten the directors with a lawsuit if they did not release her. She was released in full labor and gave birth to her daughter by cesarean at a private clinic.
The final boundary I will discuss is a more fluid one, which is negotiated by the very women it defines and confines. This boundary was the most nuanced for the adolescent women, and where their own personal stories disaggregated them from the larger grouping of “adolescent reproducers.” More than 70 percent of the adolescent women I met had stable relationships with a male partner, usually the father of their child. While not all the women were married, they hastened to assure people who questioned them that they were in a long-term, stable relationship. By adding nuance to this category, in many ways the women were separating themselves from the “bad” adolescents who had children outside of marriage/stability, and defining themselves as more responsible and legitimate in the process. Ironically, they used identical language to that of policies and physicians that was designed to create a boundary around their own reproduction. They used this language to create an additional boundary between themselves and “other,” more problematic, reproducers.
All these categories of good, bad, responsible, irresponsible create the very boundaries used in the hospital to define patients and determine the interactions the clinicians will have with them. These boundaries can be physical—tethering a patient to a gurney or moving her from one stage of birth to the next. They can be verbal—where comments about age occur with those about cooperation and responsibility. They can also be reinvented—as when the adolescent women themselves use the boundaries to define themselves as more worthy reproducers that others. The emphasis on definitions and boundaries is possibly an effort from all parties to regain control over the uncontrollable, move out of the liminal, and emerge once again into a known structure.
Vania Smith-Oka is associate professor of anthropology at U Notre Dame. Her book, Shaping the Motherhood of Indigenous Mexico (Vanderbilt), addresses the effects of a large scale development program on indigenous women’s reproduction. Her current research investigates how medical students acquire the knowledge and attitudes of medicine.