Ethnographies of Breastfeeding

A while ago I was asked to review two ethnographic texts for the RAI Journal. Two distinctly different styles of writing – here is what I thought:

 

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Falls, S. (2017). White Gold: Stories of Breast Milk Sharing. Nebraska: University of Nebraska Press

 

 

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Van Esterik, P. & O’Connor, R. A. (2017). The Dance of Nurture: negotiating infant feeding. New York: Berghahn Books.

 

 

Anthrolactology – the anthropology of breastfeeding, lactation and human milk is a growing sub-field that brings together evolutionary, medical, biological and social anthropologists.[1] The term arose out of an effort to recognise the contribution that emerging anthropologists were making in taking this specialist knowledge on nurture beyond the borders of the discipline. I would describe anthrolactology as both an expertise and a movement, through which a mapable geneology of lactation anthropology is gradually emerging. Since 2013 there has been a regular release of edited collections and monographs that strive to evidence infant feeding as a lens for understanding the human condition and the inherently sociality of survival. The two recent publications under discussion in this review are a welcome contribution to this growing family tree. The first monograph by Susan Falls, professor of anthropology at the Savannah College of Art and Design denotes a shift from her previous focus on the diamond trade, to follow a path leading from her own experience as an adoptive parent navigating the human milk sharing economy in the US. The second book under review is a joint venture by medical anthropologists Penny Van Esterik and Richard O’Connor. This text situates infant feeding within the concept of the social womb, a biosocial set of caring practices under constant threat from the forces of modernity. Where Falls is exploring milk sharing in the US through ideas about the creation of anticapitalistic and resistance space as a way of demonstrating the relationship between anthropology and architecture as art, Van Esterik and O’Connor urge us to see nurturing practices as negotiation akin to a carefully choreographed dance.

White Gold by Susan Falls (2017), invites us to explore meanings of capitalism, technology, motherhood, and risk via informal milk-sharing networks in the US. In the US (at least in areas where sharing networks operate) breastfeeding and non-profit milk sharing is presented by Falls as a resistance to state governance and ultimately, biocapitalism. Yet, this is complicated by the dominant ideology of breast is best being one that historically arises from actual state efforts to shape infant feeding habits and regulate maternal (and arguably infant) bodies. This contradiction is not lost on Falls as she invites readers to consider milk sharing as one ‘small piece of the solution’ towards human survival in an increasingly ‘serious environmental, political and economically challenged world’. The narrative throughout this book breaks free the debate on the right way to feed an infant to concentrate on the product itself as driver of this complicated gift exchange.

White Gold navigates the reader through the complex web of consciousness raising, research and relationship building involved in the moral and gift economy of milk sharing. It is as much a lesson in the serendipitous practice of fieldwork at home as it is in the cyber-ground network of breast milk feeding practices in the US. Falls positions the book as semi-autoethnographic from the outset, a style not uncommon of work dealing with intimate bodily practices. Describing how her ‘perspectives as a mother and as an anthropologist are complementary’ she positions herself from the outset by describing her connection to milk sharing networks as an adoptive mother of two and the initial access this afforded her. Each subsequent chapter is preceded by a thoughtfully selected artwork and related history meant to sensitize the reader to the overall theme under discussion. These works also serve as a reminder of the power of religion and politics in shaping our worldview of infant feeding and female bodies. This visual methodology provides a somewhat clunky transition into each chapter topic – from the practical movement of milk from donor to donee, to moral economy, the politics of breastmilk and the unconventional challenge to biocapitalism that emerges from sharing networks. Whilst a quiet revolution of milk sharing is taking place in the US (and in other post-industrial countries), the ‘milk race’ as Falls refers to it has well and truly begun for venture capitalists. The underlying message of her argument is that whilst capitalism and scientific knowledge remain dominant, the gift giving economy of milk will remain on the back foot.

One limitation of this book is the convenient gap of biocultural evidence and clinical research on the distinct make up of breastmilk to meet the needs of isolated mother-infant dyad. Skimming over this by describing the possible benefits of sharing of antibodies does not suffice, particularly for the reader familiar with the subject of human lactation. In the attempt to ‘cleave breast milk from breastfeeding to look at shared milk’ Falls is missing some significant and evidence-based points about the substance itself. Much of the mystery about the chemistry between maternal-infant bodies (biological or otherwise) which creates this tailored nutrition unique to each pairing is the elephant in the room throughout this book. Like other ethnography on infant feeding in high-income countries, it raises more questions than answers. It does however contribute to the lack of studies on human milk and infant feeding practices in a post-industrial economy context. Fall’s ethnographic material and analysis firmly interrupts the flow of milk between breast and blood-kin infant allowing for a wider, more nuanced and less biologically determined study of early nurturing practices.

Van Esterik and O’Connor are invested in the anthropological study of breastfeeding as nurturing, a practice that goes above and beyond nutritional necessity to provide a space for an ethics of care that challenges biological essentialisms. Foregrounding their work in a similar way to Falls with a narrative on how the authors became attached to their research subject. Similarly, both books evoke elements of Tim Ingold’s thinking on the creativity of habit and research driven by an ethics of care. Albeit in different ways both White Gold and The Dance of Nurture present the human condition as constant inquisitiveness leading us to research topics that have impacted on our lives in some profound way. The theoretical frameworks presented in these books remain refreshingly incomplete, demonstrating the continuity through which learning and habit forming as creative process is perpetual.

The Dance of Nurture (2017) unites the combined lactation and child nutrition expertise of anthropologists Penny Van Esterik and Richard O’Connor. Split into four sections, the chapters move through nurturing theory and practice encompassing anthropological connections between environment, kinship, fragmenting modernity and sustainable futures. Van Esterik’s work has been called upon often by those studying any aspect of human milk and breastfeeding practices in a biosocial context. This joint project with O’Connor is a welcome addition and culmination of many years work in research and advocacy. In many ways this recent collaboration provides the opportunity for her to unpack and connect what is essentially a life-time’s work on the subject. Arguing that human beings breastfeed by custom rather than instinct, the first chapters set out a ‘strong biocultural’ framework as an approach that fuses the biological with the cultural, so that neither one dominates. Together, biology and culture constitute and are constituted by breastfeeding, gaining occasional priority over each other only to quickly re-merge. In an attempt to grapple with the much under-developed area of life-course anthropology, the initial chapters introduce us to the interconnecting concepts of the social womb and the commensal circle consistently drawing upon the expertise of both authors. Together these ideas provide the conceptual space to explore nurture and feeding as a continuous process throughout the lifecycle.

The authors’ own fieldwork in Southeast Asia is combined with other regional ethnography to highlight the local diversity and plasticity in nurturing practices among mothers and infants in the same society. The ethnographic chapters are introduced to test the biocultural framework and explore in detail themes including separation, collective person-making, vulnerability, intergenerational cycles and substance. The employ ethnography of Southeast Asian feeding styles in transnational settings to ask what can be learnt that may inform our universal understanding of early nurture and biocultural development. Shifting to a worldview of infant nutrition and governance, lactating bodies and hungry infants provide a universal constant within a biocultural framework of analysis. The beliefs and practices which adapt in response to the fragmented force of modernity show that there is a continuing need across cultures to maintain breastfeeding as a nurturing custom. Ethnography and mother’s realities show us that the biocultural reasoning behind this is varied and complex.

By shifting the dominant (and tired) arguments about breast verses bottle to questions about how humans nurture others, Van Esterik and O’Connor provide new perspectives on the ‘big questions’ affecting the human condition and sustainable futures such as climate change and poverty. By developing new theory towards life-course anthropology, combined with a biocultural history of breastfeeding scholarship, ethnographic narrative and a carefully argued critique of global governance and policy targeting child development, maternal health and the anti-poverty strategies, The Dance of Nurture could easily be adopted as a syllabus text. Though it lacks sufficient ethnography to satisfy the anthropological pallet, it works well as an introduction to critical thinking in global health for those traditionally schooled in medicine or midwifery models of care.

These two books earn a valued place in the growing library of ethnographies of breastfeeding and human milk, though for different reasons. Both works strengthen the position of activism in the anthropology of human development and caregiving. Slowly chipping away at the shift needed in ethnography to move to a more overt reflexive form of practice that positions the senses and physicality of the researcher as a central tool in ethnography as method – without steering away from the subject matter and groups under study.

White Gold and The Dance of Nurture are united by a concern for future worlds, food sharing and the Anthropocene. They engage with new ways of thinking about human survival and sustainability and provoke practical challenges to biocapitalism and global health governance via the body politic. Yet unwittingly or perhaps unconsciously they both invoke the importance of the present via immediacies of feeding. Shared milk must be stored and delivered in a timely fashion or it becomes useless; a biological mother (according to a medicalised model of nurture) must connect with her newborn with the postpartum period for breastfeeding to be successful. Whether the subject is American family making, Southeast Asian economic migrant flows or women at the mercy of economic development in the global south, ethnography of human milk flows and nurturing practices reveals that increased choice (or competition) about the best way to feed comes about more as a result of increased limitations than the supposed freedoms produced by modernity.

 

[1] This term first came about through a AAA meeting panel in 2014 organised by Aunchalee Palmquist and Cecilia Tomori. The panel was organised in response to the growing visibility of contemporary ethnographic studies in this area that firmly situated human milk and feeding studies within a biocultural framework.

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#MidwivesMatter and we should treat them as we expect them to treat us.

I’ve never been one for keeping quiet about my love for midwives and midwifery. Any hint of discussion in the popular media and I find it difficult to ignore (just like now, when I should be drafting my next job application). This morning for instance, I was unable to leave my parked car and get back to the office because BBC Radio 4 consumer programme You and Yours were having a call-in about the UK Health Secretary’s announcement that 3000 more midwives are going to be pulled out of a hat to meet the massive shortfall in the NHS. This need was also pitched alongside the depressing statement that the UK has one of the highest infant mortality rates in Western Europe.

I spent some time in my car shouting at the radio, tweeting furiously about the Health Secretary’s role in eradicating independent midwifery, stripping students of NHS bursary’s and generally screwing up anything maternal health related during his time in the role, the fact that a rise is infant mortality is also down to the exclusion of vulnerable groups from healthcare due to impossible charges for non-UK/paperless residents etc etc etc My number 2 son who was in the car with me begged to be let out before I continued further.

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The UK is often touted as an example of publicly funded midwifery-led care that should be learnt from and emulated where possible around the world. Thanks to Mr Hunt this is a rapidly declining recommendation, yet it still pops up in discussions where midwives are even less valued by the state than they are here.

This report popped up on my twitter feed today. Quoting the excellent work of Canadian midwifery professor Saraswathi Vedam, the report argues for the greater role of midwifery-led birth care in the US. With the usual idealistic view of midwives in Europe, Canada and Zealand – without saying so a particular kind of midwifery from the white folks  as this model of institutionalised and regulated health care is. When I read this commentary, alongside listening to the discussion on my radio, I also inevitability think of my own research in Mexico. The long, long long debates and conversations I have with my research partner and friend Cris Alonso about trying to get midwifery even recognised a profession in Mexico, let alone through the doors of a public institution or university. I’ve come to realise how much we (as researchers, policy makers, families, educators) demand from midwives. Whether they be traditional birth attendants in low-middle income setting, or independently practising below the radar in a country that prohibits home birth, or over-regulated, overworked and underpaid in a rich country’s public health system – we want a lot.

Yet at the same time as demanding more (or less) midwives, stretching out their responsibilities and scope, bringing them under ever closer scrutiny, what I ask are we doing for them? 

The midwifery models of care across cultures and histories promote an ethics of care, one that centres women as experts in themselves, values intergenerational knowledge and above all a concern for the environment in which women grow and bear children. When will governments, policy makers and users of health services apply the same philosophy to the women who take up the profession and vocation of midwifery? We cannot expect these people to work miracles unless we provide them with the respect, resources, tools, autonomy, educational opportunities and environment to do so. As the hashtag implies #MidwiferyMatters , but certainly no more or less that the midwives who practice it.

 

Broken Bodies: the paradox of improving maternal health in low-middle income countries

Written by Jenna Murray de López, Programme Director of HCRI’s MA in Humanitarianism and Conflict Response. 

Measuring the quality of maternal health outcomes is not isolated to the moment of birth. As Dr. Princess Nothemba Simelela (WHO Assistant Director-General for Family, Women, Children and Adolescents) recently stated: A good birth goes beyond have a healthy baby. A new WHO guideline released in February 2018 demonstrates that global health governance is finally coming to terms with the idea that quality and equity in maternal health is more than just a mortality numbers game. Something that midwives and medical anthropologists have been arguing for decades.

An emerging challenge to our understanding of why women die as a consequence of childbearing is a phenomenon referred to as part of the obstetric transition – moving from the natural history of pregnancy and childbirth towards institutionalization of maternity care, increasing rates of obstetric intervention and eventual over-medicalization. Whilst increasing access to hospitals in low to middle income countries (LMICs) is improving maternal mortality in the core stages of labour, the growth in obstetric intervention is paradoxically causing an increase in late maternal mortality (deaths that occur more than 42 days but less than one year after the termination of pregnancy). In short, it is now recognised that the obstetric transition does not equate to better quality in care and improvements in mortality. This recognition is to be celebrated; however, in the rush for evidence-based medicine fans to pat themselves on the back, we are in danger of losing sight of non-mortality implications of obstetric transition, that impact on women’s health throughout the life-course.

Abuse and Mistreatment in Childbearing

In 2014 the WHO declared the mistreatment of women during childbirth and associated human rights violations a ‘global problem’. The issue was further highlighted in 2015, as UN and regional human rights experts issued a joint statement explicitly calling on states to address ‘acts of obstetric and institutional violence’. Despite this, international and regional standards on abuse and mistreatment of women during birth remain in the early stages of development. Moreover, the testimonies of women who are subject to violence remain on the periphery of knowledge and drivers of change.

Naming Obstetric Violence

Ideas, arguments and debates about mistreatment and abuse during childbirth have been most developed in Latin America, where the term Obstetric Violence grew out of activist movements in Venezuela, Argentina and, more recently, Mexico. Though the terminology has been contested by global health institutions, obstetric violence is a term well suited to the Latin American context. Recognised as a form of gender-based violence (GBV), it has been incorporated into national legislation aimed at women’s rights to live a life free from violence. As a collection of acts and consequences obstetric violence is now clearly defined, yet it remains little understood in terms of the direct impact on women, and the inherent muddiness between emergency medical treatment and systemic misuse of intervention. At least by naming the abuse as violence, broader links can be made to societal influence outside of the institution.

My own research in Mexico argues that it is a form of GBV precisely because it is done to women because of who they are (biological reproducers) and what they represent (moral subjects). Obstetric violence violates women’s reproductive health rights, and results in physical or psychological harm during pregnancy, birth and postpartum. The measurable signs of a violent and dysfunctional system in Mexico include a 50% caesarean section rate in the public sector, with estimates of up to 85% in the private hospitals; and episiotomy as routine practice.  Perpetrators of obstetric violence can be lead clinicians, though they can also be nurses, student doctors and other support staff – regardless of gender. Obstetric violence earned its name because it happens within the space of obstetric logic, it happens as a direct consequence of the obstetric transition.

Obstetric violence is both direct and structural and this means it is complicated. Large public facilities in LMICs (and beyond) are understaffed and understocked, providing a stressful environment where professionals are unable to ensure levels of care that are kind and respectful. Unlike other forms of violence, treating perpetrators of obstetric violence as criminals detracts from the problem that is inherently structural. Imposing criminal sanctions on health personnel who commit acts owing to serious weaknesses in the health system leaves the causes at the heart of the phenomenon unresolved, resulting in inefficient measures to resolve incidents of violence. All the whilst the pressure to improve maternal mortality rates and meet global development goals mean that women in LMICs are left with little choice but to be treated in an environment that will no doubt scar them in some way for life.

The right to live or die, receive respectful medical care and have autonomy throughout pregnancy, birth and puerperium are heavily loaded concepts when so much is at stake politically and professionally. The stitches from unnecessary interventions may only take weeks to heal but as is evident in the wealth of testimonies coming out of Mexico the trauma of abuse will last throughout the life-course.

 

Maternity Leave is not a Sabbatical

‘In many ways I have found maternity leave to offer some of the valuable aspects of a sabbatical.’

The following post is my response to a recent article on the @GnHigherED Academics Anonymous column. Before I go any further, I must stress this is not a sideways attack at the person who wrote the column. I am not in the business of public (or private) attacks against my fellow academic primary carers. The author clearly had a very positive experience both in terms of early motherhood and the time afforded by her employer to go through this transition. And that’s great.  stronger-together-cme-save-the-date

My issue with this post, and clearly one of numerous respondents on my twitter feed, is the underlying message that mat leave offers a period to catch up on the research activity that so evades us when we are working. The author refers to the luxury of having the choice, not the pressure to work. I’m not happy with what this implies.

I do not speak from a position of bitterness, I speak from a position of experience. Those who know me personally, or have read my PhD blogs about motherhood during fieldwork and writing up, will have heard me joke about my PhD Babies. In the past I have referred to my two bouts of academic maternity leave as my strategy for completion. It always made me chuckle, but this article has given me pause to reflect.

I worked through my maternity leaves out of necessity. I could not afford to complete a PhD in Anthropology, with a years’ fieldwork and a year’s writing up. I too was fortunate to be in full-time employment whilst I studied with generous provision to leave when I became pregnant on two occasions. My PhD babies are now in school, their early months a distant memory – they appear to have suffered for nothing. I however realise that for 3 of my 4 children I spent their first years barely surviving and on many occasions ambivalent about their presence because I had a deadline to meet. It took me just as long to get to an age where I had the confidence for HE as it did for me to decide I wanted a family. I did make a choice, but choices come from limitations not freedom. 

I strove through the 6yrs of my PhD and motherhood, because my first mentor in HE informed me she had decided to forego having children because she didn’t believe in academia you could be successful at both. I wanted to prove her wrong.

This anonymously written article has touched many nerves on social media, and in doing so has served to highlight just how many women do not have a positive experience, and return to work seriously disadvantaged and behind their male or child-free colleagues. Working on maternity leave for a large amount of the population is born of fear and necessity that their careeer opportunities will be stunted by the demands of caregiving. There are clear problems with how one becomes a ‘successful’ academic (via over-production and free labour) and the support available to make a family in a healthy and economically viable way.

 

 

Quality over quantity: The true cost of improving maternal mortality in Mexico

If like me you are unable to make the presentation of my AAA paper with my amazing co-researcher and academic midwife Cris Alonso, I’m reproducing it here, enjoy!

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Quality over quantity: The true cost of improving maternal mortality in Mexico

Paper presented at the American Anthropological Association, Annual Meeting 2017, Washington DC.[1]

Cristina Alonso, MPH CPM, Luna Maya and Jenna Murray de López PhD, University of Manchester

Recent reflections on the successes and failures of Millennium Development Goal 5 (MDG5) have led researchers, policymakers and practitioners to recognise that the excessive medicalisation of pregnancy and birth, and emphasis on increased access to emergency facilities do little to guarantee equity and quality of care. Moreover, increases in integrated prenatal care programmes and facility delivery have failed to have any significant impact on maternal mortality ratios (MMR) in low to middle income countries (LMICs).[2] With an increase in facility based services, incidents of disrespect and abuse in childbirth have been documented across the globe[3]. Large public facilities that are understaffed and understocked provide a stressful environment where maternal health care practitioners are unable to ensure evidence based clinical care that is kind and respectful.  Threat of mistreatment and abuse has led many women to avoid accessing facilities all together, and seek alternative and more respectful forms of care.[4]

Qualitative evidence demonstrates women’s preferences for continuity of care and trusting relationships, as well as local traditions and beliefs surrounding the social significance of childbirth often outweigh free access to technocratic, facility-based services.[5] The “Midwives Voices Midwives Realities” report established that midwives working in facilities are disrespected, harassed, bullied , underpaid, unsafe and overworked[6]. It has been well established that quality care includes kindness and compassion towards women, as well as self care of midwives[7]. This cycle of abusive care is global and must be addressed to achieve excellence, evidence and rights in MNH.

World Health Organization, United Nations Population Fund and the International Confederation of Midwives all state that midwives are the ideal provider for maternal and newborn health worldwide. The Lancet “Midwifery” series details how “midwifery is a vital solution to the challenges of providing high-quality maternal and newborn care for all women and newborn infants in all countries”[8].  Research into disrespect and abuse has begun to reveal however that midwives by themselves are not enough, they require professional autonomy and integration as competent professionals. Even though facilities may hire midwives, these are not “optimised for low-risk women, and staff monitor and intervene more than is necessary for the overwhelming majority of women”[9]. As a consequence, the term “Too little, too late and too much too soon” has come to describe low and middle income countries maternal health[10]. The push to prevent maternal mortality has driven women to large birthing facilities, and has contributed directly to a significant increase in cesarean rates, presenting added risks for women and babies and increased mortality for women[11]

Though midwives and midwifery exist, in some form or another, in all countries across the globe, there is a distinct lack of (quantitative or qualitative) data in LMICs that have no, or little professional recognition of midwives or adequate recording systems for out-of-hospital birth outcomes. Over recent decades LMICs have experienced rapid population growth and intense urbanization. It is estimated that more that 45% of LMIC populations now live in towns or cities. Yet, it is precisely out-of-hospital birth practices in towns and cities that remain the least understood and understudied. This deficiency of data, which would be able to offer a broader understanding of the ways and means in which women give birth in an urban context, is an issue for policy and implementation of strategies that aim to improve quality, choice and sustainability of infant-maternal health for large urban populations.

In this paper we report on a case example of two midwife led birth centres in Mexico, from which data has been recorded using the MANASTATS system for 10 years[12].  We present an overview and preliminary analysis of essential outcomes between 2007 to 2017, recorded in the Midwives Alliance of North America Statistics Project dataset (MANA stats version 2.0 and 3.0). The MANA stats dataset includes nearly 200 variables including: demographics of women and families; pregnancy history and general health; antepartum, intrapartum, neonatal, and postpartum events and procedures; and maternal and newborn outcomes. The variables referred to in this paper include type of birth (vaginal or caesarean section; level and type of intervention; transfer rate and mortality outcomes. We argue that this alternative accounting, using a limited sample size (N=559) is still capable of indicating quality of care, and as such has significance for global accountability and quality agendas. Whilst the birth centre data set is not comparable to facility based data sets, we ask what this level of data can tell us about birth outcomes in alternative birth spaces, what assumptions can be made about low-intervention data? And furthermore, when complemented with qualitative data, what kind of community based health indicators arise which are grounded in local ideas about what constitutes quality and respectful maternity care?

In a global health context we argue that that despite important reductions in maternal mortality and morbidity, more progress is needed to ensure all women have access to quality care that is culturally respectful. Mexico’s national maternal mortality fairs no worse than the richer states of its northern neighbour, however its cesarean section is much higher than any developed country. Wide spread health reform over 25yrs has gradually increased accessibility to healthcare and more women than ever are receiving prenatal care and birth attention at little to no personal financial cost. We propose that Mexico provides a fruitful case example because of recent national efforts to professionalize midwifery in response to high maternal mortality for income level (38 per 100,000 births[13]) and cesarean rates (49%[14]) There is potential for comparison with other Latin American, Eastern European and South Asian LMICs characterized by women having high induction and cesarean rates coupled with high rates of disrespect and abuse. Drawing from 18 months ethnographic fieldwork (Murray de López) and 13 years of clinical  experience in south and central Mexico in midwifery and public health (Alonso), we ask how our data helps us think through the following questions: Is the equity and quality agenda central to the SDG approach really any different from the MDG approach? What can women’s avoidance strategies during pregnancy, birth and postnatal tell us about poor quality care? Is maternal mortality enough of an indicator to know that women are safe? And in relation to this, is it possible to improve quality and reduce mortality and morbidity at the same time.

In these contexts, women begin to seek alternative birthing practices and providers to avoid intervention, unnecessary cesarean and abuse.

Alternative Accounting

The quantifiable evidence base approach in global health is driven by an emphasis on Random Control Trials (RCTs) as statistically viable ways of creating health indicators. Calculated as rates, ratios and percentages, health indicators quantify the qualitative experience of human life. This approach requires large amounts of data to be statistically robust. In the case of maternal health, mortality and fertility rates become the evidence base for the health and wealth of a nation and the basis for intervention.  This emphasis on the collection of ‘good numbers’, raises questions about what kind of data and what sorts of outcomes should be considered as valuable.[15] Much work carried out by small-scale organisations and independent health-workers remains ‘uncountable’ within this system and therefore remains unaccounted for. In the field of critical global health, arguments have arisen for alternative forms of accounting, which consider local interventions and cross-culturally defined health indicators.[16] Thinking critically about numbers is an attempt to rethink what is meant by evidence, rather than shift the ways in which it is gathered. Alternative accounting asks how we might account for the impact of small scale or periphery services. It argues that accountability should not focus upon what can be counted, but on how service providers can be held accountable for quality and equity. It also argues that accountability be based on local values, which in this case would be women´s perceptions of safety, quality and equity in maternal health. It is an approach that does not reject statistics, but asks that they are recognised as ‘partial, created, fallible stories’ that need to be accompanied by other forms of less measurable evidence, in order for interventions to be not only targeted, but meaningful and sustainable.

Safer Motherhood

The concepts of safe and safer motherhood have been universally defined however, what constitutes ‘unsafe motherhood’ is less clear. Whilst notions of what is ‘unsafe’ about pregnancy and birth go undefined, there remains a space for misinterpretation and manipulation at both local and global levels. A dangerous and unhelpful dichotomy appears where facility based intervention equates to ‘safe motherhood’ and anything other than facility based care (and the people who provide it) equates to ‘unsafe’ with no measurable evidence base. In LMICs where emphasis is placed upon providing increased access to institutions, in order to adhere to safer motherhood principles, less is known about the alternative spaces that women seek for pregnancy, birth and postnatal care.

Midwifery led birth centers (MLBC) are often not considered or counted as “facilities” or “obstetric units”.  MLBCs are expanding globally as a mid point model between seemingly “unsafe” home birth and “overly medicalized” facility births. Birth centers in the US and Canada and midwifery led units in the UK and Netherlands consistently demonstrate outcomes comparable to homebirth rates in HIC which include low intervention rates including cesarean and high satisfaction[17].  Research on outcomes of MLBCs is lacking in countries where midwives and MLBCs are not integrated into the health system. The Goodbirth Network has identified over 480 birth centers across the globe, and operating in countries where there is no regulation for this practice. Mexico is one example, where birth centers exist and are run by midwives but national regulation focuses solely on hospitals and is undefined around homebirth. In these cases, births at MLBCs are considered homebirths and will be documented as “unqualified care” outside of an healthcare facility. This begs two questions: what difference does lack of regulation incur in outcomes of women seeking out of hospital care with midwives in unregulated countries, if any?  And secondly if women are receiving improved care in MLBCs, as the model would infer, documenting these births as “outside of a health care facility” and “attended by an unqualified provider” would need to be revisited.

Out of hospital birth in urban Mexico

Midwifery in Mexico is currently not understood to be a profession, nor is there acceptance of the midwifery model of care as a desirable norm for most women. Over 88% of births are attended in health care facilities and 87% by a physician (INEGI, 2016). There are multiple obstacles that preclude midwifery care as an option within maternal health in Mexico. While there has been a commitment to integrated medicine in the public sector, such as the Intercultural Hospital in San Cristobal de Las Casas, and recently “Humanized Birth” areas in maternity hospitals in Tula, Hidalgo and Tlaxcala, there are different and conflicting opinions and visions how to achieve “integrated medicine,” which includes midwifery care. Access to midwifery education is limited and job placement post graduation is scarce.

A strong and growing movement from within and outside of the government in support of the professionalization of midwifery and its integration into the health sector recognizes the need to create trained and qualified midwives and provide health care that is centered on women´s values and choices, particularly given the cultural diversity that constitutes Mexico. The Ministry of Health recognizes the need to integrate multicultural solutions to a multicultural nation.  In 2009, the Ministry of Health, through its Center for Gender Equity and Reproductive Health program, published the “Holistic Strategy to Accelerate the Reduction of Maternal Mortality in Mexico.” (SSA, 2014). The strategy recommended the hiring of non-medical providers, such as professionally trained midwives, obstetric nurses and perinatal nurses for prenatal and birth care. In order to achieve this, the hiring code that recognizes Obstetric Nurses (Enfermeras obstetricas) was reinstated in 2008 and in 2011, and a hiring code was also adopted that recognizes professional midwives. In 2016, the Norm 007 that regulates the care of women during pregnancy, birth and postpartum was reviewed recognizing obstetric nurses and professional midwives as qualified providers and  their need to provide training to traditional midwives.

In Mexico there are approximately 10 birth centers that offer services under the midwifery model operating with no regulatory framework and outside of the health system. On the one hand midwives refer to be afraid of the health system because of fines, closures and legal reprisals and on the other hand, the health system expresses confusion about how to regulate these spaces without a regulatory framework. There are no specializations aimed at midwives which may provide them with tools for the direction and management of birth centers, or a view on operating a business model, human resources management, leadership, administrative, accounting and finance skills, and legal orientation. Nor is there an expert body that can advise and support birth centers according to a successful business model and negotiate with the health system based on a regulatory framework.

Despite the effort of gratuity and trainings on “nice treatment culture (cultura del buen trato)” promoted at healthcare facilities, more and more women seek for midwives for their sexual and reproductive care, as they try to avoid the obstetric violence experienced or perceived both in public and private institutions. Birth centers offer a physical space to ensure the implementation of the midwifery model.

Research conducted by Sanchez in 2016 exposed that although midwives have sought regulation and integration of birth centers, health authorities have repeatedly denied the value of homelike environments and midwifery autonomy as safe for women[18].

Luna Maya Birth Centers provide a model of community-informed maternal and family health care in two locations in Mexico: Mexico City and the southern town of San Cristobal de Las Casas near the Guatemalan Border. The flexibility of the model allows for the integration of international best practices and guidelines into the existing culture of care that has been informed and determined by women in the community it serves. The growth and success of Luna Maya’s model of care is largely due to this human-centered approach to practice implementation. Luna Maya seeks to expand the models associated with community-based midwifery care, and through this expansion has found an innovative way to meet the needs of two distinct groups of women and families in both San Cristóbal de Las Casas in Chiapas and in Mexico City.

What MANA stats data tells us

Data was contributed by 4 different midwives, including CPMs, unlicensed direct-entry midwives, apprentices. All out-of-hospital births (home, birth centre or other[19]) were attended by a lead CPM or unlicensed direct-entry midwife, aside from intrapartum transfers (see fig1.).

The total dataset consists of 618 archived forms of which 500 birth outcomes are recorded (502 newborns in total) and comprise the final sample (N=500). Briefly, 87% of women in the sample self-identified as mestiza Mexican and/or Hispanic, of that number 8% as indigenous, and the remaining 23% as other nationalities/ethnicities. It is important to note that the MANAStats data form does not include a variable that indicates indigenous Mexican. Most women paid for midwifery care out-of-pocket, with a small percentage receiving subsidised or free care dependent on economic status or vulnerability. Employment or State insurance in Mexico will not cover out-of-hospital birth. Between the sample period of 2007-2017 there were no maternal deaths and a total of 5 neonatal deaths were recorded which include previously known anomalies and anomalies detected at birth (within 6 weeks postpartum, see fig.3).

Antenatal Risk Status

High risk women were risked out of out of hospital birth care but were welcome to receive pre and postpartum midwifery care. Risk referral includes chronic diseases such as diabetes and cardiac problems. Pregnancy complications such as preeclampsia and gestational diabetes were referred. Previous cesareans were not risked out nor were twins and breeches, although full informed consent was given and women themselves chose referral or care by midwives. It is important to note that in some occasions, women opt to birth out of hospital despite being high risk due to fear of obstetric violence or non-consensual care. Age, parity, education and socio-economic status were considered for care provision but not risked out.

The reason risk criteria remains so flexible is because often women seek care from Luna Maya because they have been automatically scheduled for a cesarean in the public or private sector. Currently in Mexico women under 18 and over 35 and previous cesareans are automatically labelled as high risk and scheduled for cesarean despite ample evidence to the contrary. Some women who were risked out refused to transfer care- as in the case of several breeches, one after a previous cesarean, three severely malformed fetus´ and one diabetic and stated they would birth on their own before attending a government facility. The outcomes in some of these births were not good, including neonatal deaths, and highlight the added risk of systemic obstetric violence among high risk women which may push them to pursue suboptimal clinical care, choosing kindness and respect over technology. In all of these cases Luna Maya provided care as ethical review by midwives concluded that women deserve care always.  Although more research is necessary to describe these specific outcomes, it is important that women who are at high risk for complications are occasionally opting out of obstetric care due to perception of disrespect and abuse.

Mode of Birth

MLBC place of birth pie                  MLbc mode of birth pie

Fig.1 Place of Birth                                                              Fig.2 Mode of Birth

(Note: Other is women´s shelters that include a womens’ safe house and a shelter for single indigenous women)

Of the sample of 500 women, 85.6% completed an out-of-hospital birth (n=500). The spontaneous vaginal birth rate for the sample was 90.2% including vaginal births in the hospital. Of the 428 out-of-hospital births, 49 women had a vaginal birth after one or two or three previous caesarean sections (VBAC, VBAC2, VBAC3). The VBAC success rate for women over the complete sample was 85,2%. A total of 6 out-of-hospital births were breech presentation.

Transfers and Complications During Labour

The total intrapartum transfer rate, over the ten-year period, was 14% (N=72) of all planned out-of-hospital births. Of the 72 intrapartum transfers, 13 were urgent transfers, 49 of which resulted in caesarean section, giving an overall caesarean section rate of 9.8%. There were 5 postpartum transfers from the whole sample (3 urgent) and 7 neonatal transports (5 urgent). It is important to note that all women are out of the midwives’ care as soon as transfer takes place, though women will often return to the birth centre for postpartum care and only an insignificant amount become lost to follow-up. It is also important to note that in Chiapas the great majority of intrapartum transports result in cesarean section due to the lack of a sympathetic and supporting obstetrician, whereas the majority of transports in Mexico City resolve in vaginal birth due to a highly supportive obstetrician who includes the midwives in the continuity of care at the hospital.

 

Fig. 3 Out-of-hospital labour and birth complication characteristics
Shoulder dystocia n(%) 14 (2.8)
Thick or particulate meconium n(%) 13 (2.6)
Blood loss over 500 ml n(%) 89 (17.8)
Blood loss over 1000 ml n(%) 14 (2.8)
Pre-eclampsia.eclamsia during pregnancy/labour n(%) 5 (1)
Intrapartum transfer n(%) 72 (14.4)
Postpartum transfer n(%) 5 (1)
Neonatal transfer 7 (1.4)
Maternal deaths 0
Infant death before 6 weeks Postpartum 5

Conclusion

Reflections on the successes and failures of Millennium Development Goal 5 have led researchers, policymakers and practitioners to recognise that the excessive medicalisation of pregnancy and birth, and emphasis on increased access to emergency facilities do little to guarantee equity and quality of care. Moreover, increases in integrated prenatal programmes and hospital facility delivery have failed to have any significant impact on MMR in LMICs. By contrast, with an increase in access to hospital maternity care, incidents of disrespect and abuse have arisen as part of a global phenomenon. Large public facilities that are understaffed and understocked provide a stressful environment where maternal health care practitioners are unable to ensure evidence based quality care. In LMICs like Mexico where policy is only just beginning to recognise the possibility of technical midwives as a vital part of public health services, there is little to suggest their presence would impact on improving quality and equity. In fact, by entering an existing environment of disrespect, midwives may eventually be accused of contributing to worsening the experience and outcomes for women. Therefore, damaging the possibility of their growth as a specialist profession.

Despite this problem, the better promotion of midwifery-led care remains vital for the improvement of maternal health as a global concern. In order for this to happen there needs to be a more detailed picture of the different practices and environments within which midwives practice with autonomy. As part of this, alternative forms of accounting should be sought that consider locally based interventions and culturally defined health indicators. Accountability should not focus solely on what can be counted, but on how service providers can be held accountable for quality and equity. As a way of working towards this, this paper has presented preliminary data of outcomes from two established MLBCs to show what can happen under an alternative system of low-risk management of maternal health. The data described here presents the need for a more in-depth and broader understanding of midwifery-led care and out-of-hospital birth in the urban context of LMICs. In conclusion, we advocate for wider implementation of the MANAStats data system, adjusted to be culturally appropriate, amongst midwives attached to MLBCs in towns and cities of Mexico. Furthermore, that this form of data collection be complemented with qualitative research and be considered seriously in the future development of respectful and equitable maternal health care.

 

[1] Alonso, C., & Murray de Lopez, J. (2017). Quality over quantity: The true cost of improving maternal mortality in Mexico. Paper presented at the American Anthropological Association, Washington DC.

[2] Wendland CL. 2016. Estimating Death: A Close Reading of Mortality Metrics in Malawi, in Metrics: what counts in global health, Adams V (ed).  Duke University Press: Durham. p. 57-81.

[3] Bowser D and Hill K. 2010. Exploring evidence for disrespect and abuse in facility based childbirth report of a landscape analysis, USAID-TRAction Project, Harvard School of Public Health, University Research Co., LLC.

[4] Molina RL, Patel SJ, Scott J, Schantz-Dunn J, Nour NM. 2016. Striving for Respectful Maternity Care Everywhere. Maternal and child health journal, p. 1-5.

[5] Davis-Floyd R, Barclay L, Daviss B, Tritten J (eds). 2009. Birth Models That Work. University of California Press: Berkeley, California.

[6] World Health Organization. 2016. Midwives Voices, Midwives Realities, Retrieved from: http://www.who.int/maternal_child_adolescent/documents/midwives-voices-realities/en/

[7] Byrom S and Downe S. 2015. The Roar behind the Silence, Why kindness, compassion and respect matter in maternity care. Pinter and Martin Ltd

[8] The Lancet, Midwifery Series, June 2014

[9] Shaw D et al. 2016. Drivers of maternity care in high income countries: can health systems support women- centered care? The Lancet, Maternal Health Series pp. 52-65

[10] Miller S et al. 2016. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide The Lancet, Maternal Health Series pp. 19-35

[11] Freyermuth G, Muños JA and Ochoa MdeP. 2017. From therapeutic to elective cesarean deliveries: factors associated with increase in cesarean deliveries in Chiapas. International Journal for Equity in Health 16:88

[12] Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Development and validation of a national data registry for midwife-led births: the Midwives Alliance of North America Statistics Project 2.0 dataset. J Midwifery Womens Health. 2014 Jan-Feb;59(1):8-16. doi: 10.1111/jmwh.12165. Epub 2014 Jan 30.

 

[13] INEGI, 2016

[14] Freyermuth et al (2017)

[15] Adams V, Craig SR, Samen A. Alternative accounting in maternal and infant global health. Global Public Health, 2016. 11(3): p. 276-294.

[16] Adams V (ed). Metrics: what counts in global health. 2016, Duke University Press: Durham.

[17] Alliman J, Phillippi J. Maternal outcomes in birth centers: An integrative review (in press). J Midwifery Womens Health 2016; 61.

Hollowell J, Li Y, Bunch K, Brocklehurst P. A comparison of intrapartum interventions and adverse outcomes by parity in planned freestanding midwifery unit and alongside midwifery unit births: secondary analysis of ‘low risk’ births in the birthplace in England cohort. BMC Pregnancy & Childbirth. 2017;17:95

[18] Sanchez Ramirez, G (2016) Espacios para parir diferente, un acercamiento a Casas de Parto en México. El Colegio de la Frontera Sur

[19] ‘Other’ in this dataset refers to a local women’s shelter housing indigenous women in vulnerable or violent situations and the women´s shelter for battered women.

data: 199 homebirths, 72 transports. Other is womens shelters.

Deciding what matters in everyday maternal health

Maternal health is a key indicator of a country’s progress in improving both health equity and social inequality. At least this is what I read on an almost daily basis, it becomes an opening statement to my grant bids and a mantra I repeat often in the classroom. I do on many levels believe this is true. I have previously, in broader terms argued that the way in which a society treats women, is an overall indicator of oppression and inequality in said society. So it follows suit, maternal health may be one way in which this is reflected. Yet, beyond the grand statement, how do we prove this is so? What kinds of evidence counts, and who gets to say so?

I’m juggling a few (sparsely funded) projects at the moment. Making sure that whatever the outcome of my next contract timeline, I have a CV that reflects I’ve achieved something and that daily academic duties have not torn me too far apart from my research topic of choice. Contract precarity is not something I mean to discuss in this post or this blog at all. But I will make this optimistic point – it is forcing me to focus, tame my possibility tentacles and make sure I have an overall project that not only relates to my current post, but can move with me if I need to. Realistically, that does play a part in deciding which aspects of gender, relationships and health I throw my energies at.

I’ve got the core debates down, I know that MMR is a key yet slippy issue, I’m glad that global health has finally listened to social science and recognised that quantity does not equate to quality in health care provision. I am energised by the standard of amazing work coming out of medical anthropology in terms of challenging metrics, RCTs and the politics of universality. Moreover, I have gained enough in confidence to recognise that I must work with and not against my colleagues in medicine if change is ever likely to occur. My interactions within the institutional realms of health have become as much a source of field data as when I am wandering clueless and happy through the neighbourhoods of urban Chiapas. I am finally hitting on a way to enmesh the rhetoric with the everyday. I have spent enough time in my own fieldnotes to constantly ask of policy – “But what would this mean to …..?” “What would she/they have to say about this claim …?” or “Does this matter to …., what would they say was important”. In other words, my interlocutors have become my method through which I analyse and evaluate the claims of global health.

As the brilliant anthropologist Vincanne Adams and her collaborators argue, new is not always better and time must be taken to evaluate success in a localised sense, before the next big idea springs into action. The ‘slow research’ method (i.e. ethnography) proposed by Adam’s and her colleagues offers a direct challenge to the market demand for innovation in global health research. In this respect I am taking a moment to pause, go back to the beginning of my overlapping projects, and also the drivers behind them. In doing so I will repeat some old questions, to see if I am offered insight and a different perspective. Using my most established field contacts and the written down conversations I have had with them over the years, I begin from today to ask what maternal health is in an ethnographic sense, and moreover what matters to those living through it? My challenge is to define Everyday Maternal Health, at least in a Mexican context and over time find some clarity over local variance and priority – one that can confidently contribute to macro ideas about what women actually, and really need to address the power imbalances in their lives.

Watch this space …

 

Breastfeeding when it suits (somebody else’s agenda)

As world breast feeding week begins my twitter timeline is overflowing with the celebration of the milky boob, it’s place in the world as saviour of all, how all mothers should be supported to feed when and where they wish, how breastfeeding is and should be the norm, it’s natural, it’s amazing, it’s simply the best etc etc you get the idea!

Whilst yes on some level, all of those things are true, back down in the real world life is complex, economies cause suffering, gender inequality and structural violence are certainly not a thing of yesteryear, and breastfeeding discourse becomes another way of imposing things onto women’s bodies.

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Some argue that reduction in exclusive feeding from birth is a phenomenon of industrialisation and capitalism. Whilst others argue that the practice of exclusive breastfeeding has never really existing both historically and culturally across the globe – the two factors which are often thrown around in feeding or milk reduction debates. Anthropologists have confidently shown how the idealised model of exclusive feeding for six months from birth is based on practices of women living in the global south, who have no other choice due to food scarcity. On the other hand, anthropologists have also shown how the politics of feeding has always involved manipulation by formula milk companies, who are at the root of the depletion and quality arguments surrounding breast milk and nutrition. You see, I said it was complicated. And I haven’t even touched upon the objectification of women’s bodies, sexual trauma, male lactation and milk sharing!

What I observe ultimately, in my research and teaching, is that breasts, human milk and the maternal body as provider of a unique substance that science cannot beat continues to be more, rather than less, of a contentious subject. It seems that the more we (claim) to know, the more emotive and creative the arguments. Making global health initiatives, like World Breastfeeding Week  subject to a barrage of standpoint arguments and shouting matches – that ultimately distract from its aim, which is to better the conditions for women who wish (via cultural necessity or desire) to use their bodies to feed and nurture their offspring. And I suppose that’s my point here, any concern for breastfeeding should start with the woman who makes the milk in the first place. It is a social issue but it begins with an individual, and it is she who knows what is best – which may or may not be for her, her breast.