Wednesday, April 15, 2015

Notes from the Field: Learning with Indigenous Midwives in Chiapas, Mexico

Mounia during the Day of the Dead fiesta
November 2014
Today's post is a guest article from anthropologist Mounia El Kotni. Mounia's "Notes from the Field" appeared in the most recent Council on Anthropology and Reproduction newsletter, and she has kindly allowed its reproduction here. In this post, she describes her participant-observation experience with midwives in Chiapas.

Learning with Indigenous Midwives in Chiapas, Mexico

“Oh, I see, so you want to be a partera (midwife)” is the typical response I hear after explaining the purpose of my visit; that I am doing dissertation research to document how midwives live and work. Although I try to explain my research goal in terms of “helping raise awareness on the difficulties parteras are facing,” I am always met with this same response “so you want to learn how to become a midwife?” And as I have gotten to meet parteras and aspiring midwives, I must admit that there is not always a clear difference between what I do and how I act and what they do and how they act: asking questions about pregnancy care, sitting in on prenatal consults, taking notes on almost everything the partera says... There is a thin line between participant-observation and midwives’ apprenticeship model. And indeed, I have been learning a lot about how parteras work and live, but also a hell of a lot about plants given in pregnancy care and massage techniques.

Since October 2014, I have been in San Cristóbal de Las Casas, Chiapas, conducting dissertation fieldwork and volunteering for the Women and Midwives’ Section of the Organization of Indigenous Doctors of Chiapas (OMIECH). As a volunteer, my work consists mainly of two tasks: administrative tasks (aka looking for funding) and logistical support during events and workshops. Since 1985, OMIECH has been strengthening Mayan medical knowledge and organizing health workshops in indigenous Tseltal and Tsotsil communities of Chiapas. Even though I am in Chiapas, some of my notes echo those of Kara E. Miller (Fall 2014 Newsletter). Here too, the parteras - who are referred to as Traditional Birth Attendants in international documents - are frustrated with the lack of possibilities to transfer their skills to the next generation. This is why the Women and Midwives’ section organizes workshops focused on reproductive health, and care during pregnancy, birth, and postpartum. These workshops are open to all members of the community where they take place, and aim to perpetuate botanical and medical knowledge by transmitting it to younger generations.

Micaela giving a workshop at the meeting of OMIECH parteras
February 2014. credit: OMIECH
The loss of knowledge is accelerated by various factors: young people’s migration, midwifery not being an attractive profession economically, and also the increasing medicalization of birth. The push to send women to birth in hospitals comes with a delegitimation of indigenous parteras’ knowledge as “not-modern”. Through conditional cash-transfer programs (documented by Vania Smith-Oka in the state of Veracruz), women are pushed to have their prenatal visits and give birth in hospitals. Parteras, on their end, have to attend trainings given by the Health Secretary. These trainings emerged in the 1980s, and intensified in Chiapas under the pressure of reducing maternal mortality rate to comply with the Millennium Development Goal (Chiapas has one of the highest maternal mortality rates in Mexico). Indigenous traditional midwives either have to follow the trainings or stop practicing. This can have dramatic consequences in places where they are often the only health care provider in their communities.

Micaela during a community workshop with parteras.
May 2014. credit:Alice Bafoin
As I jot down notes during an interview or observation within these different settings, I feel a thrill of delight when their words echo one another. But then I realize this means that these state policies are really achieving great changes for parteras. And like Sisyphus, tirelessly, my colleagues at OMIECH reweave what is being unwoven: traditional medical knowledge, but also, and as important, pride in it and trust within the community.

While “in the field”, my notes are scribbly at times, crystal clear at others, but rarely absent. I try to type them regularly, as a good apprentice-anthropologist, but have stopped feeling guilty when I could not do so. It took me a few months to be able to “let go” and admit there will always be an event I will miss, a trip I cannot make... At my mid-point in the field (already), I have just started to take drawing classes, which helps me expand the range of my notes, when words fail to describe a hand gesture, or when I do not know the terminology for this exact point on the belly that needs to be massaged. These classes have made the familiar look different, and made me look at people in a new way, which in turns adds more depth to my notes. Life in the field intertwines professional, political and personal spheres. The friendships I have built through this research promise to impact both my career and personal life. As we were searching for plants in the garden of the organization for an upcoming booklet publication, my colleague Micaela corrected me as I got the name of the plant wrong, once again. I could sense, for the first time, an impatient tone in her voice. I pause and I suddenly realized that although I am not studying to become a midwife, every one of the parteras I have met has been a teacher to me, training me a little bit, sharing their story, their tortilla and their endless knowledge. I am looking forward to learning a lot more in the next five months I will be spending with them and I hope my dissertation will bring them knowledge they can use in their struggle.

Mounia El Kotni is a French-Moroccan doctoral candidate at the State University of New York at Albany. Her dissertation documents the impact of Mexican health laws on the practice of indigenous midwives. She is currently conducting fieldwork with the Women and Midwives Section of the Organization of Indigenous Doctors of Chiapas (OMIECH). Since 2012, Mounia is also a member of the French organization Association Mâ, which promotes respected childbirth. She can be reached at

Wednesday, April 1, 2015

Notes from the Field: When Breastmilk Isn’t Enough

Veronica and 4 month old Paulo
Today's post is a guest article from anthropologist Veronica Miranda. Veronica's "Notes from the Field" appeared in the most recent Council on Anthropology and Reproduction newsletter, and she has kindly allowed its reproduction here. In this post, she reflects on her time spent in the Yucatan while she was breastfeeding and conducting field research.

When Breastmilk Isn’t Enough

It was a hot and humid late July afternoon when I decided to pay a visit to one of the village midwives. I gathered my already-packed research bag and on the way out I said good-bye to my husband (a.k.a. field assistant and nanny) and kissed our three month old son. It was around three o’clock when I left. The heat was still unbearable as I walked through the rural Yucatec Maya pueblo of Saban, located in the southern interior of the peninsula.

When I arrived to the midwife’s house I was hot, sweaty, and thirsty. I was escorted by the midwife’s daughter to the large newly built thatched roof kitchen located behind the house. Elda, the midwife, was cooking lunch when I got there. She invited me to sit down and eat with her family. We had a simple but delicious lunch.

Elda served a thin soup of boiled Chaya (a dark leafy green high in calcium and folic acid) that was mixed with ground-up pumpkin seeds, sea salt, and a generous squeeze of fresh lemon juice. Her son had picked some avocados from the tree outside and made a big bowl of guacamole. And like all meals in the pueblo, our lunch was accompanied by fresh, handmade corn tortillas. It was one of my favorite meals. I ate two servings and savored every bite.

Elda was happy that I liked her cooking and she said I must always be hungry because I am breastfeeding. She told me she ate often when she breastfed her children many years ago. I asked her if she exclusively breastfed her three children—two girls and a boy. She said yes. In fact her son, the youngest, was the largest of all her babies. He was so big that many people thought he was a year old when he was only six months. We had already had many conversations in the past about the importance of breastfeeding for both baby and mother. Yet at that moment, I had to ask her a question that had been bothering me for some time. I asked, “Elda if I am exclusively breastfeeding my infant son and he is visibly a large and healthy baby, why are so many people in the community telling me I needed to supplement with formula? Why are they saying he needs more than breastmilk”?

Elda took a moment to think about what I had just said and then asked if my son cried a lot. As a young first-time mother away from my own familial support system, I was not really sure the average amount a baby cried. My son did cry often throughout the day and night but I was usually able to sooth him by breastfeeding. From the day he was born I nursed my son on demand—even at eight months he was still adamant about having breastmilk every two to four hours. In the end, I answered Elda’s question by saying “Yes, he does cry a little”. Her teenage son was intrigued by our conversation and asked me if my son had air in his belly? Assuming this was similar to colic I explained that this used to be an issue, but not anymore. Elda suggested that he could have mal de ojo. But she was leaning more to the idea that maybe I was not producing enough milk. She asked if my milk was soft or hard when it leaked through my shirt. I paused for a moment—I had never been asked this question before. Was she referring to my milk flow or the thickness of my milk? I probably will never know since I did not ask her to explain. Not completely understanding the question I said I think it comes out soft.  

She said that was it. My son cried a lot because he was hungry, she explained. My milk was too thin and he was not getting his fill. I asked her what I could do to fix this, and she responded by saying, “Usually if the mother has thin milk, about a month after the baby is born, she is told to drink a lot of agua de Chaya and follow a local remedy of placing boiled orange leaves over the her breast and taking a warm bath with the tea water. The mother must stay inside for three days, especially if it is cloudy outside. This will help increase the milk supply and make it thicker”. Unfortunately, I had missed my chance. My son was almost four months old and my best option now was to supplement with formula.

I thought about this conversation with Elda the rest of the time I was in the field. Just a generation ago, women in the community exclusively breastfed. The older and middle aged women who told me I needed to supplement with formula had exclusively breastfed their own children. Women have always breastfed. Breastfeeding continues to be widely practiced throughout the community. As Elda pointed out, local healers and midwives have used traditional remedies passed down from older generations to help a mother increase her milk supply and sooth a crying baby. But times have changed; today, breastmilk is no longer seen as enough. Many women firmly believe that infants need to be supplemented with formula. The idea that traditional medicine is no longer able to help women produce enough milk to feed their babies is relatively new. Formula, for many women, provides the necessary nutrients infants need to thrive. These beliefs are instilled through the advice of local doctors and nurses, and reinforced by widespread media and public health campaigns. Today the majority of new mothers believed that their infants would be healthier and happier if they had both breastmilk and formula.  

There is a wide array of literature that explains why indigenous and/or poor women choose to use infant formula. Some reasons include 1) the belief in corporate media messages proclaiming the superior health benefits of formula; 2) indigenous women’s internalization of the idea that their bodies are inadequate; 3) a rise in social status with the use of expensive formula; and 4) the adoption of the idea by indigenous and/or poor women that they are better mothers by offering formula to their children. I knew all of this going into my fieldwork. I have read the literature, and studied the political economic histories that have affected and shaped rural women’s choices. Yet, it was not until I personally experienced in the field the issue of supplementing with formula that I had a greater appreciation for the many ways in which women address on a daily basis the health of their children. As a young researcher eager to apply the scholarly knowledge I had gained I chose to focus heavily on the issue of breastmilk verses infant formula. But I was wrong. After many conversations with women in the community I was finally able to listen to them and understand that they did not see the two as a binary. It was until much later that I realized the women suggesting I supplement with formula were trying to help me deal with a situation and address a specific symptom—a crying baby. These rural Yucatec Maya women are bombarded with constant messages by doctors and from the media that their bodies are insufficient at meeting the needs of their unborn and infant children. As with childbirth, these women have not addressed their health and that of their children through an either/or dichotomy. Women are trying to make the most of all the resources they have and mixing practices allows them to ensure the wellbeing of their children. It was shocking to see how strong the outside messages of the inadequacy of women’s bodies had affected their beliefs, yes, but even within that these women are trying to find the best ways to raise healthy and happy children.

Veronica Miranda is a doctoral candidate in medical anthropology at the University of 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.

Wednesday, February 25, 2015

Reducing Primary Cesareans (Part 2)

Click here to read Part 1: The Primary Cesarean Reduction Movement

I just listened to an interesting webinar on Preventing Primary Cesareans! The presenter explored much of the research and data supporting the recommendations behind the SMFM and ACOG Statement Safe Prevention of the Primary Cesarean Delivery. I found a few of the points interesting enough to share them here.

Ideally the primary cesarean reduction issue would be addressed through a systems approach, where hospitals, payors, patients, and OB providers are all working to improve primary cesarean rates. This presentation mainly focused on the obstetrics areas that can be influenced to make change.

The presenter noted that the Healthy People 2020 target cesarean rate for low risk, full term, singleton, vertex pregnancies is 23.9%, BUT that the goal in 2010 was 15%. Clearly, the government had to lower its expectations.

Malpresentation contributes to 17% of pre-labor cesareans, and is a highly modifiable obstetric indication for preventing the first cesarean. For example, research shows that an external cephalic version at greater than 36 weeks has a success rate ranging from 35-86%. Care providers and hospitals should be offering and encouraging this procedure. Furthermore, more clinicians need to be trained in how to vaginally deliver breech babies. The presenter only recommended this when the second twin is breech. Vaginal breech delivery of the second twin does not increase morbidity when done by an experienced provider.

Failure to progress (or CPD) accounts for about 34 - 47% of intrapartum cesareans (the majority first stage arrest), and nonreassuring fetal status (heart rate tracing interpretation) accounts for about 10 - 27% of intrapartum cesareans. These are additional modifiable areas to prevent cesareans. 

A big one is Failure to Progress, aka labor arrest, aka cephalopelvic disproportion. This can be diagnosed during either first stage or second stage (pushing). We joke in the doula world that this is often "failure to wait." Many OB's are taught that labor progresses according to the Friedman's Curve. This curve is one of my biggest birth pet peeves. This curve basically says that during active labor, a primiparous woman should dilate about 1 centimeter per hour, and that (on average) the entire first stage should last about 13 hours. This is based on a 1955 study with a sample size of 500 primips. It looks like this:

A 2010 multicenter study of more than 200,000 deliveries looked at primips and multips. This study found that the 95th% was about 20 hours for the first stage, with a mean of 8.4. (Keep in mind that half of the women received pitocin and 80% of the women had an epidural). Here is the curve from this study. It shows that multiparous mothers generally have shorter labors and that active labor may not really get going for them until about 6 cm dilation. Then, the curve is quick. For first time moms, however, there is no definite "turning point," and the curve is more gradual. 

This is a reason for the big change to starting "Active Labor" at about 6 centimeters dilation and not diagnosing labor arrest unless the mother is not having cervical change for 4 or more hours after they are at least 6 cm dilated. Moreover, diagnosis of labor arrest in the second stage has also changed due to this study, which found longer pushing stages for first time mothers as well as for mothers who had an epidural. Much research has shown that no neonatal morbidities were (statistically) significantly increased as length of second stage increased. Some maternal morbidities were found to increase (statistically) significantly as pushing time increased (e.g. uterine atony).

Another important point is that we need to give women who are induced more time to labor! There are few adverse outcomes associated with increased patience for inductions. The recommendation is at least 24 hours of pitocin + no regular contractions + no cervical change = arrest. 

The presenter suggested that to addressing variation in diagnosis of nonreassuring fetal heart tones, we should really emphasize that moderate fetal heart rate variability is reassuring, as is FHR acceleration after fetal scalp stimulation.

I'm going to share her slide here so you can see what she lists as the non-medical factors in the hospital and among care providers that influence cesarean rates.

I liked that she addressed that the hospital has trouble with allowing women to labor longer on L&D, that OR staff often go home at about 8pm so many Cesareans are scheduled before then so no one has to come back to the hospital at night, and that nurses are very busy and have competing priorities. Physicians of course have their own personal reasons for "diagnosing" a cesarean, among them financial incentives to deliver the child themselves so they will get paid and not someone else! Research shows that hospitals that have salaried MDs (e.g. laborists; can also be midwives) have less variability in the time of day when diagnoses of fetal distress are made. 

She touches on myths among patients (labor is bad for the baby, long labor is bad, induced labor is the same as spontaneous labor, operative vaginal delivery is worse than cesareans, etc). This is something that childbirth educators and doulas try to impress on the public, but physicians need to be doing this education, too. 

She did not cover medical legal issues due to time constraint (understandable - it is a major topic)! I would have liked to hear, though, ways that nurses can be involved in preventing the first cesarean. I work with a hospital that shared that they are getting their nurses educated and involved in educating and working with patients on how position changes can help the baby descend, pelvis open, and reduce first and second stage labor time (and nonreassuring fetal heart rates). I think this is a great initiative!

The presenter did mention doulas when prompted, praising their involvement, and the involvement of midwives, but did not touch on how they can make a difference in reducing primary cesareans. 

If you'd like to see the entire slide set or check the references, you can download the slide set from the National Perinatal Information Center website when they become available.

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