Risk, Reproduction and Narratives of Experience - Hardcover

Hardcover

ISBN 10: 0826518192 ISBN 13: 9780826518194

Publisher: Vanderbilt University Press, 2012

Synopsis

As Carole Browner explains in her foreword: ""These chapters compellingly reveal that although we anthropologists tend to speak of biomedicine in hegemonic terms, in fact its penetration is quite variable and often ambivalently met. . . . Risk, Reproduction, and Narratives of Experience sheds new light on a troubling core aspect of medicalisation processes, which simultaneously render pregnant women more docile subjects even as they are impelled to actively engage with biomedicalised prenatal care regimes. . . . We also see that a consummate means by which states seek to consolidate power in the reproductive realm is through expansion of the biomedical concept of risk. This critical observation emerges repeatedly in this collection.""

About this title

About the Author

Lauren Fordyce is a Visiting Assistant Professor in the Department of Sociology and Anthropology at Bucknell University.

Amínata Maraesa is Lecturer in the Department of Anthropology at Hunter College of the City University of New York and the Department of Latin American and Puerto Rican Studies at Lehman College of the City University of New York.

From the Back Cover

Vivid ethnographies of reproductive risk and responsibility that speak to the conflicts between pregnant women and mothers and state-sanctioned biomedicine

Excerpt. © Reprinted by permission. All rights reserved.

Risk, Reproduction, and Narratives of Experience

By Lauren Fordyce, Aminata Maraesa

Vanderbilt University Press

Copyright © 2012 Vanderbilt University Press
All rights reserved.

ISBN: 978-0-8265-1819-4

Contents

Foreword Carole H. Browner, ix, 
Acknowledgments, xiii, 
Introduction: The Development of Discourses Surrounding Reproductive Risks Lauren Fordyce and Aminata Maraesa, 1, 
Part I Complications in Measuring and Defining Risk, 
1 Conceiving Risk in K'iche' Maya Reproduction Matthew R. Dudgeon, 17, 
2 Failing to See the Danger: Conceptions of Pregnancy and Care Practices among Mexican Immigrant Women in New York City Alyshia Galvez, 37, 
3 The Vital Conjuncture of Methamphetamine-Involved Pregnancy: Objective Risks and Subjective Realities Alison B. Hamilton, 59, 
Part II Biopolitical Narratives of Risk and Responsibility, 
4 Birth and Blame: Guatemalan Midwives and Reproductive Risk Sheila Cosminsky, 81, 
5 "They Don't Know Anything": How Medical Authority Constructs Perceptions of Reproductive Risk among Low-Income Mothers in Mexico Vania Smith-Oka, 103, 
6 Local Contours of Reproductive Risk and Responsibility in Rural Oaxaca Rebecca Howes-Mischel, 123, 
7 New Countryside, New Family: The Discourses of Reproductive Risk in Postsocialist Rural China Qingyan Ma, 141, 
Part III Struggles over the Embodiment of Reproductive Risk, 
8 Negotiating Risk and the Politics of Responsibility: Mothers and Young Child Health among Datoga Pastoralists in Northern Tanzania Alyson G. Young, 157, 
9 Shifting Maternal Responsibilities and the Trajectory of Blame in Northern Ghana Aaron R. Denham, 173, 
10 Imaging Maternal Responsibility: Prenatal Diagnosis and Ultrasound among Haitians in South Florida Lauren Fordyce, 191, 
11 A Competition over Reproductive Authority: Prenatal Risk Assessment in Southern Belize Aminata Maraesa, 211, 
Afterword Rayna Rapp, 231, 
Contributors, 235, 
Index, 237, 

CHAPTER 1

Conceiving Risk in K'iche' Maya Reproduction

Matthew R. Dudgeon

In the department of Quetzaltenango in Guatemala's western highlands, different meanings of risk attach to pregnancy and its management for three distinct groups of health care providers: local physicians, regional workers for an international NGO working to improve health quality in maternal and infant health services, and K'iche' Maya traditional birth attendants (TBAs)—midwives, or, in Spanish, comadronas. Moreover, theories of risk that focus on the state as a source of power and the administration of risk may be inadequate for conceptualizing local TBAs' meanings of reproductive risks. Many TBAs work with a multilayered discourse of risk within which they rate their clients' pregnancies, as well as evaluate each other's worthiness of the title comadrona. Indeed, midwives in rural Guatemala perceive their relationship to the supernatural as a mitigating force against the risks associated with pregnancy. Midwives who purportedly strike a pact with the devil may find themselves outside the parameters of local definitions of what makes a good midwife.

Background to Experiences of Reproduction in Cantel, Guatemala

For most of the twentieth century, the government of Guatemala interacted with its rural population as a sovereign power. State administration of that population was achieved primarily through force rather than infrastructure or social services, and it has differed according to locally recognized ethic distinctions between indigenous Maya and ladino groups of Spanish ancestry. Such regulation of the rural population has helped exclude indigenous groups from state politics, maintained a semi-feudal concentration of land and resources in the hands of a small minority, and supported some of the highest levels of inequality between the richest and poorest in the Latin American region (Suarez-Berenguela 2001). Throughout Guatemala's postcolonial history, national political debate has focused less on the inclusion of indigenous communities and more on the degree to which sovereign versus disciplinary and regulatory power should be exercised by elites in the administration of those communities; strategies have included privatization of land and indigence laws with forced labor directed at indigenous groups (Handy 1984).

While in the nineteenth and twentieth centuries Quetzaltenango's indigenous K'iche' elite class has wielded political power, much of its authority rested on administration of land and community relations of reciprocity, increasingly undermined as K'iche' elites depended more heavily on the state and its punitive powers. At the same time, a growing K'iche' middle class of merchants and artisans called for health and educational reforms and increasing integration of the Guatemalan state into local administration in the departmental capital (Grandin 2000). The prevalence of sovereign power has produced both fragmentation among indigenous communities and a limited degree of autonomy within them—an autonomy shattered for many communities as the state shifted from isolated massacres to total war, development poles (army-administered communities), and community policing during Guatemala's civil war in the 1980s. In the aftermath, and in parallel with the activities of international organizations such as the United Nations and bilateral and multilateral NGOs, Guatemala has seen increased administration of the biopolitical life of rural Maya, with a particular emphasis on reproduction and reproductive health. Most recently this shift has included the establishment of a Ministry of Reproductive Health and the pursuit of a plan for indigenous health, both implemented under Guatemala's Integrated National Health System (SIAS) and with the stated goals of reducing infant and maternal mortality (Cosminsky, this volume; Maupin 2008, 2009).

While conducting research on reproductive health in a K'iche' Maya community in the municipality of Cantel in Quetzaltenango, I encountered great variation among groups of health care providers in the meanings they attached to infant illness and death.2 Conducted from December 2001 until May 2003, my ethnographic and epidemiological fieldwork focused on Maya men's experiences of reproduction, as well as men's influences on maternal and infant health. The peri-urban municipality provided an ideal location to investigate reproductive health in a Maya community that had, relatively speaking, good access to the health facilities of the urban center of Quetzaltenango and yet, like many parts of Guatemala, still experienced relatively high rates of infant mortality. With a population of nearly 99 percent indigenous K'iche' Maya, the municipality of Cantel had 729 live births in 2001 and an infant mortality rate of 53.5 per thousand, higher than Guatemala's overall rate, estimated between 39 per thousand in 2000 and 45.8 in 2001 (CIA 2011).

I located my research in one aldea (hamlet) of Cantel, a community with a population of approximately 3,500, where I also conducted multisited ethnographic fieldwork with several groups of health professionals. These included physicians and epidemiologists working with the Ministry of Health, several local and regional health NGOs, and collective organizations of TBAs. I conducted semi-structured and open-ended interviews and attended planning and training meetings, gathering data via observation of physician training in reproductive health, interviews with traditional midwives, and verbal autopsies from families in the community after stillbirths and perinatal and infant deaths. Those data provide insight into the differences and similarities in concepts of reproductive risk between groups, as well as implications for the provision of health care by those groups.

Risk among Biomedical Health Care Providers

One dimension of my fieldwork involved characterizing the levels of reproductive health care. I worked with TBAs as well as physicians, nurses, and other biomedical health care providers. In the departmental capital of Quetzaltenango, I attended a conference and training session on maternal and infant health at the departmental office of the Ministry of Health for regional doctors and hospital staff. The conference included lectures and slide presentations that focused on measurements of mortality and morbidity, vaccination campaigns and their outcomes, and epidemiological data on the quality of health care provided by the Ministry of Health.

The concept of risk arose concretely during a presentation by a local physician who had worked for the last several years with maternal and infant health NGOs receiving funding from USAID. His current work with an NGO had shifted focus from the training of TBAs (cf. Cosminsky, this volume) to the assessment of indicators of quality in different health care settings run by the Ministry of Health, such as hospitals and health clinics. Factors measured included the presence and quantities of essential supplies and medicines, number of beds in different wards, and sanitation in and around the facility. In his presentation on quality control, he spoke of the creation of "emergency plans" with couples during their pregnancy. The NGO's focus on education regarding preventive measures for obstetric emergency was targeting the vast majority of the couples in indigenous communities like the K'iche' community in Cantel in which I worked, who planned to deliver in their own homes with TBAs rather than in a hospital. Although some of these same couples would readily go to the hospital if the pregnancy proved complicated, others were resistant. Emergency plans ostensibly allowed couples to have a course of action in place in the event of an obstetric crisis—planning ahead who might drive if delivery occurred at a time when buses were not running, having some money set aside for the transportation, and deciding the roles husband, extended family, in-laws, and TBA would play. Each plan included training in how to recognize signs of danger in the pregnancy and during labor. This effort incorporated some elements of training given to TBAs in Maya communities by earlier NGO projects, along with some focus on education for couples.

The theme of the physician's talk, introduced as part of the justification for emergency plans, was that providers' understanding of the risks of pregnancy had to change. Rather than the "old" way of thinking about pregnancy—that some subset of pregnancies had complications that had to be managed, such as obstetric emergencies that required physician intervention—the speaker's project advocated the perspective that "every pregnancy is at risk." Pregnancy was to be thought of as an inherently unstable period during which the health of both mother and fetus was at risk. Rather than wait for an obstetric emergency, or rely on prenatal care to sort women into categories of complications, pregnancies by their very nature should be thought of as risky.

This view brought immediate murmurs of dissent from the crowd of physicians and mutterings throughout the rest of the talk. Discussion afterward was brief but heated and revolved around the statements of several physicians in the audience that pregnancy is a normal, healthy biological process, a part of life, and that to call pregnancy inherently risky flew in the face of basic reproductive physiology. The presenter was conciliatory, saying that much of the risk of pregnancy depended on context—limited resources, rural, poorly educated, and indigenous. But he did defend his position that pregnancy and delivery are complex physiological processes, that some part of that process might go wrong with any pregnancy, and that every pregnancy is at risk.

I was initially surprised by the other physicians' vehement reaction to the premise that all pregnancies are risky. At face value, it seemed a rather subtle shift, and a realistic one in a setting of limited resources and historically poor indicators of maternal and infant mortality. My first assumption was that physicians would embrace any expansion of the field of health care (making every pregnancy, rather than just a few high-risk pregnancies, the domain of doctors) rather than reject it outright. In speaking with some of the physicians in the audience after the talk, I did hear this perspective voiced—but about the presenter and the NGO, not about themselves. As one physician put it: "This idea of all pregnancy being risky, it's nonsense. Look around. Look in the hospital and in people's homes. The vast majority of pregnancies turn out fine. Saying that every pregnancy is risky is just a way for projects to expand, to self-justify, and to get more funding. We need to spend money on the pregnancies that are actually in trouble, rather than projects with fancy talk about risk."

The presenter had his own insight into the crowd's reaction: "I've seen this reaction before, when I give this talk. They have an older idea of risk, one that's based on their training as doctors, that risk is about pathology, about being sick. They see risk as out there somewhere, a germ or an accident, rather than a part of the process of pregnancy and childbirth."

Between these two views I see a fundamental shift in the way risk connects the individual pregnant woman to the population served by biomedicine. For the physicians, risk is more discrete, with pathology an outside threat. For the NGO worker, however, it is more pervasive, a field to be navigated rather than a threat encountered. Moreover, physicians are removed from the universe of blame unless they fail in their intervention in a pathological pregnancy. But from the perspective of the NGO worker, blame extends in all directions, making lack of prenatal care a risk factor for poor pregnancy outcome. This second perspective resonates strongly with Agamben's (1998) state of exception, in which a condition of constant emergency allows the powers that be to suspend rights and exert total control—a mechanism to import the older sovereign rules into modern structures of power.

Implicit in the discussion—and much more explicit in my ongoing work with physicians and hospital workers—is the idea that the reproduction of some groups is riskier than that of others. The reproduction of indigenous Maya occurs in a dense cloud of risk, not unlike the fog that hangs over the chilly cornfields of their highland mountain communities, where distance, inaccessibility, poverty, illiteracy, and culture obscure access to biomedical facilities and blur perceptions of dangerous reproductive practices. Hospital staff I had previously interviewed in two neighboring departments (Dudgeon 2000) felt a major contributor to Guatemala's high infant and maternal mortality was the late arrival of complicated deliveries to the hospital such as those that included prolonged or obstructed labor, hemorrhaging, and asphyxia. Arriving at a health facility far into the course of the complication, many of these cases were "too late" to be managed by biomedicine. This lateness was framed as needless and exacerbated by informational and cultural barriers, including the TBA/midwife, who perhaps did not recognize the complication in time or who, along with the patient and her family, did not want to go to the hospital until the final moment (see Cosminsky this volume for an extended discussion of TBA training in Guatemala). This differential field of risk echoes Ginsburg and Rapp's (1995) use of the concept of stratified reproduction (cf. Colen 1995), by which the reproduction of members of some groups is encouraged and facilitated, while that of others is limited and hindered.

These attitudes contrast with the attitudes toward risk held by some K'iche' TBAs in the communities of Cantel. Each hamlet of that community is served by a handful ofTBAs, locally known as comadronas and as iyom or ilonel (in K'iche'). Some of these TBAs practice only in the hamlet in which they live, while others may have clients spread over several communities in the municipality. Some work only with a few patients, such as members of their extended family, while others have many more clients and support themselves through their work as midwives. Some of the women are in their seventies and have been practicing for decades with little formal training, while others are in their twenties and have received government or NGO training courses but have little real-world experience. Many of them have delivered numerous infants both before and after receiving government or NGO training. While some are relatively isolated in their practice, most participate in a loosely organized guild, which focuses on facilitating training by outside groups and on soliciting material contributions. The most active TBAs and those with the highest client load tend to be in their fifties and sixties, delivering from a dozen or fewer to more than one hundred infants a year.

As informal and poorly integrated members of the biomedical obstetric care community, any interaction with other health care providers has meant for many midwives a risk to both their personal integrity and their professional credibility. Obstetric emergencies that resulted in trips to the hospital were failures for these TBAs, rather than the smooth shift in levels of care envisioned by NGOs and hospital staff (cf. Berry 2006). The antagonism and derision they met in hospitals was often humiliating, but more damaging for many was the insult to their reputations as professionals and, less commonly, the potential animosity and retribution they might face from families that had a difficult delivery or a poor delivery outcome. False alarms—trips made that are later deemed unnecessary—can be equally damaging.

The importance of professional credibility depended in large part on the zero-sum dynamics of midwifery practice in a small community, in which professional rivalries and jealousies created a fairly continuous background hum of blame and insinuation with and about other midwives. Such discourse in large part operates to maintain a hierarchy of reputation of good and bad midwives in an area in which no one midwife can attend all deliveries, but many work to function as health care providers at as high a capacity as possible. Such friction between midwives is balanced by the solidarity they maintain as a group in order to prevent other midwives from infringing on their territory and to compete as a group for positive attention from outside organizations such as the Ministry of Health and NGOs. Comadronas that work together to form groups are more likely to receive support (like funding, training, and equipment) and less likely to encounter problems when they do go to hospitals or interact with physicians, because they may develop ties with hospital staff and physicians and may, therefore, be perceived as cooperative, albeit ancillary, pieces of a larger technobureaucratic health care system (see Davis-Floyd 1996). Locally, however, comadronas negotiate the complex, risky moral landscape of relationships among the group of midwives themselves.

(Continues...)

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Edition details

• Publisher: Vanderbilt University Press
• Publication date: 2012
• Language: English
• ISBN 10: 0826518192
• ISBN 13: 9780826518194
• Binding: Hardcover
• Number of pages: 256
• Editor: Fordyce Lauren, Maraesa Aminata