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.


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.


Why Vanessa Maher remains my go-to for troubling global debates on breastfeeding


I’m currently working on a paper about mother’s  milk as a source of contamination and how it is dealt with in the cross-over between local and medical ideas about risk. Although comparative anthropological work on breastfeeding has (thankfully)  blossomed and advanced since the turn of the century, I wanted to take a few moments to summarise why Vanessa Maher’s 1992 edited volume The Anthropology of Breast-feeding: Natural Law or Social Construct remains my go-to text for thinking critically about global health and child rearing practices. If you wish to move beyond the recent evangelism on breastfeeding as the panacea to all inequality and question whether policy has changed tack at all, this volume is a good place to start (and a great warm-up read to the 2015 volume of Ethnographies of Breastfeeding).

First published in 1992 this edited collection remains as relevant, if not even more so today. The critiques developed in this volume, predominantly a) little is known about the cultural practices of BF in the western world; b) that universalised global health policy is often framed within the idealism of BF in the developing world – which is generally born out of economic and social restraints and bears no resemblance to the expected lives of women in industrialised and post-industrialised countries; c) the cultural and social dimension of our understanding of BF casts doubt on the accepted medical wisdom of many international organisations active in the field of healthcare.

The latter is what concerns me most in my current writing and thinking today. The most recent research and inclusion in the sustainability agenda surrounding improvements in BF is highly situated within a medical discourse. In an effort to highlight the disconnect between the value of human milk as a substance and its substitution, a paper in the recent Lancet series on BF argued: The fact that the reproductive cycle includes breastfeeding and pregnancy has been largely neglected by medical practice, leading to the assumption that breastmilk can be replaced with artificial products without detrimental consequences (Victora et al 2016:485). Whilst this may be the case, the current push to situate breastfeeding within a discourse of nutrition, maternal and infant morbidity and mortality, and human intelligence is no more helpful. Anthropology has done much work over the years on the impact of pathologizing pregnancy and childbirth – there is much we can learn from this in how we understand breastfeeding once it is captured under the medical gaze.

In the introductory chapter to the collection Maher positions a critical anthropological analysis of breastfeeding via the interrogations. These categories provide a framework for a cross-cultural examination of breastfeeding practices without falling into the trap of universalising meaning:

Breast Vs Bottle – an oversimplification

  • An infants’ survival will depend on many factors but certainly not only on having been breastfed – economic status, education of the mother, housing, access to medical care, social controls on women’s sexualities and reproductive capacities, caregiving practices. Ethnographic research in urban areas of the Philippines and Tanzania for example, has shown that the mode of feeding in the populations’ most healthy infants appears to be insignificant (:4).
  • ‘Nutritional uses’ of breastfeeding are culturally determined and this must be taken into account.

Whose milk is it anyway?

  • In many societies, the rules regarding breastfeeding are laid down by men and tend to support male-dominated institutions.
  • That younger women’s practices are often enforced by older women does not necessarily mean that ideas behind such practices originated with women.
  • Breast milk is a female resource whose cultural and institutional importance is such that men and women content for its control. Cross-cultural accounts of the meanings behind human milk as a bonding substance and feeding as symbolic connections between humans evoke gendered ownership which transcends that of the mother-child unit.

Breastfeeding and Political Order

  • Associating breastfeeding with intimacy and privacy in industrialised societies has resulted in the exclusion of nurturing practices in public spaces – That a woman should breastfeed at work or in public is a violation of cultural categories which sustain a power structure.
  • Societal rules about gender and segregation and cultural beliefs about spoiling milk impact on space and duration of feeding. Notions of pollution are apparent in all aspects of how, why and where women can breastfeed in various cultures.

Patriarchy and the Mother-Child Relationship

  • How much responsibility does a society place at the breast of the mother for emotional development and why?

Patriarchal Institutions and the Interruption of Breastfeeding

  • Patriarchy means that the relationship between mother and child is defined or even controlled by the cultural emphasis or social institutionalisation accorded to relationships involving adult men in dominant positions (:23).

Call the midwife! (to do some collaborative research)


I am in constant conversations with my midwife and research colleague in Mexico about practices, policy and the state of midwifery worldwide. It is through these whatsapp conversations and frequent skype meetings that, through identifying knowledge gaps and needs in Mexico I learn a lot about the state of midwifery in the UK.

If I have an area of doubt or lack of information (I am after all an anthropologist not a midwife) I often take to the twittersphere and mailing lists I am a member of. It is here also that I get to talk to many sages whom I neither know personally or have ever met. Midwives globally are an amazing font of knowledge, carrying out research and publishing whenever and wherever possible – unfortunately quite often to limited audiences (other midwives or maternal health and birth enthusiasts/researchers/activists like myself). This is absolutely nothing to do with the standard of discussion, it does however have much to do with medical hierarchies, authoritative knowledge systems, patriarchal and prescriptive notions of what constitutes scientific knowledge, reporting of such knowledge and who gets to own that knowledge. It is also to do with time limited studies, natures of collaborations and support given to everyday and academic midwives to carry out research. What high profile publications such as the Lancet publish amazing special editions such as this one and the much celebrated UK Maternity Review the backlash from elements of the obstetric community is massive and immediate – as evidenced in this excellent and balanced commentary by Prof. Hannah Dahlen .

Our current struggle in Mexico is that there are so much knowledge and evidence of good (and not so good) practice amongst midwives. Women across Mexico are attending enough births (also pre and post natal care) a year to gather a solid chunk of measurable variables to finally put the meat on the bones of the well worn and recognised: community midwifery models of care = better birth outcomes, better maternal mental and physical health, fewer deaths, less unnecessary surgery and VAW, strengthened communities all round. Yet these women are so busy doing just that, they have so little time and energy left over to gather the data needed (qualitative as well as quantitative) to evidence their work in the face of a massively overbearing and dominant medical monarchy.

In comparison, though the development of midwifery as a profession in the UK is vastly different to the varied practices and identities in Mexico – data collection, on the things that matter to women and midwives remains depressingly similar and for similar reasons mentioned above. The reason why I am writing this post is due to a request from my Mexican midwife for evidence on the use of Nitrous-Oxide (more commonly known as ‘gas and air’ or by it’s trade name Enotonox) in home births. My automatic response was “sure, there must be loads written about it!” After all, we tend to use the stuff like its going out of fashion whether it be at home or hospital – though reportedly (anecdotally) it is less used in home births as with most medical intervention. So how did I fair in my initial search through the ever faithful google scholar? ………Nothing, nada, zilch … I played with word order, I booleoned, I resorted to a wider net casting of blogs and online magazine sources. The nearest I got were some passing comments on its widespread use (from non-UK papers), and in the UK context guidelines on storage and use, a few posts on the possible dangers of its use (by few I mean 2) and countless birth narrative where women speak about how they felt using it during home birth and/or transfer – all of which useful to me as an anthropologist, little of which useful to store as evidence for ‘scientific’* publication. An addictive substance, administered everyday by midwives and used by women in the throws of birthing and yet there is no exploration of its use in an out-of-hospital birth pain relief or whether it plays a role in the type of birth outcome. Many midwives have an opinion on its use, as do the women who have or may use it, moreover someone beyond my personal circle must care about the role it plays in home birth outcomes. As a response to my request for references said:

Like so many of the maternal health practices around the world (UK – Entonox, Mexico – episiotomy, everywhere – elective c-section) a practice becomes the norm, the norm becomes unchallenged. Yes Entonox is part of the pain-pain free thesis but that doesn’t mean it shouldn’t come under scrutiny. There are certainly studies done in hospital circumstances (mainly by obstetricians and medical students) so why not in home birth situations? This question I think leads me back to the aforementioned reasons as to why so little evidence is recorded and collected in Mexico and the common opinion amongst midwives wherever they are from:

Anthropology has a great history of working and writing with midwives, the reproductive and feminist anthropology archives are bursting with ethnographic examples. I have spent the last 7 years working in a Faculty of Nursing and Midwifery and have often felt the a warm glow when I see well thummed and familiar ethnographies peeping out from midwifery colleague’s bookshelves. The time I have spent working around midwives in both of my home countries I have also been very aware on time and lack of support that midwives receive for carrying out on-the-ground empirical research. A 2014 commentary in the Lancet argued that Interprofessional Collaboration is the only way to ‘save every woman and child’ (UN’s strapline not mine!). With this post I am fervently arguing that Interprofessional Collaboration between midwives and the social sciences is the only way to save properly robust and challenging evidence based midwifery and woman centred research (my strapline not the UN’s!). We support our midwifery colleagues to be able to carry out even more research improving on the amazing work they already do – and we must listen to them in terms of how we are to achieve this.

*I don’t hate science, I just hate the loaded use of it as an adjective with a hidden agenda.

Writing more about less UPDATE #15minAcWri #AcWriMo

I thought it would be worth doing a quick check in as to how my writing challenge has been going mid-term. Tomorrow #AcWriMo begins and it comes just in time for me to tackle some half finished papers that have been on the slow burn! This post will look at how I’ve been using my 15 minutes of acwri and what I’ve (re)learnt about my writing habits, so that hopefully this years #AcrWriMo will be a personal success.

Okay I admit I do not have a massive teaching load this term so in many ways I am advantaged, but to be honest the regular 15 minutes that I have been devoting to the beginning of each day are helping me recognise some habits about my writing (and reading) practices that I think can be maintained even in those busier times. I’m 6 months past my PhD thesis ( 2 months past corrections) and already I’m starting to wonder how I ever got it done in between working and family life. I need to remember – because I have a stack of papers to write!

In the meantime here is how I’ve been using my 15 minute #AcWri so far:

Writing to do lists for the week: 

Everyone loves a list! (or is that just me?) Lists give my life and work meaning and give me a sense of accomplishment. Just like this one, as it is a reverse ‘done list’ a way of reflecting on what I have done over the last few weeks. ‘To do’ lists also keep my  day on track.

Writing Short Blog Posts: 

This longer post has actually taken up 3 of my 15 minutes as I planned it more than most. However what I have learnt is that I can actually write rather a lot in free form within this timescale. Writing drafts or published posts for this or guest blogs gets the ‘stuff’ out of my head and clears my thoughts for the day – a bit like the sitting down version of a morning run. After a couple of days I noticed my word count jumping up from 500, 600, 700. It’s amazing considering for my other ‘proper writing’ I can spend 6-7 hours trying to force out a paragraph or two!


Like the academics I follow for #acrwi advice (@raulpacheco, @thesiswhisperer, @explorstyle) I include reading in my acwri routines. I cannot however read an article or chapter deeply in fifteen minutes, despite my many talents superwoman speed reading is not one! Inspiring blog posts, initial reading of chapters (already identified in my to do list) and abstracts are just about what I can cover in this time – sifting through the “oooh that’s interesting” to the “I do actually need to know more about this stuff to inform my thinking/writing”. What I have found is that only online blog reading previously identified and in the list works in 15 minutes, and my failure has been clinking on links and wandering into the online ocean, only to surface 1 hour later! Not advised ..

Working on application forms: 

I have had various funding and job applications to complete over the last month, planning and proof reading my statements and CVs during a 15 minute spurt has made this a much less onerous task (ignore this sentence if you love a good application form!).

Organising Evernote: 

Been meaning to do this since I handed in my thesis and just never got around to it. 15 minutes works great for a bit of electronic filing and because I stop when the alarm goes off I stay focused and don’t sway into reading tagged material from many moons ago.


This is a tricky one and only works if you concentrate and answering yesterday’s emails on the understanding/acceptance that you will never beat that academic email mountain. If you answer yesterday’s emails and deal with them quickly 15 minutes helps you limit not only the amount of work day time you spend but also that overwhelming feeling that accompanies a full inbox.


I would like  to say to any future students, publishers, reviewers and employers that I do obviously spend full days editing my writing! However fifteen minutes is enough to edit a draft blog post, important email or statements for aforementioned application forms.

Lesson Prep: 

Knocking out a 3-5 hour lesson plan, synopsis and reading in 15 minutes is a great way to start a lesson planning day. Once that is in place you can structure the rest of the day deep reading and writing the lecture or activity you have planned without getting distracted with where you put you comfort break in.

All this counts as academic writing to me and is most definitely serving to clear the decks before what ever long term activity of the day begins. As I approach my second #AcWriMo as a fledgling academic I think the above strategies will help keep me on course.

We need to talk about … Corrections Part 2

15 min #AcWri (though not strictly as I already spent 15mins on another project this morning!)

So to recap – I defended my thesis early summer, it was a very positive experience and was done in such a way that I was able to approach my corrections without too much fear. On the downside I had to cancel most of my summer writing plans and also spent very little time with my family- which was further dampened by having no money to do anything when we were together because one of the lesser spoken consequences of resubmitting with anything more than minor corrections is a substantial resub fee!


I now realise that the secret to a happy corrections process (for me) is a) corrections that don’t require further research or oral exam b) excellent feedback and direction form examiners c) an urge to tinker with the things you found during viva revision and suddenly realised you hated d) affirmation everyday that the ultimate goal is to have a better quality thesis and know you did everything you could to make that happen.

The benefit of the oral viva in the English system is that it is a great chance to have two other perspectives on your writing. because lets face it, by the time you hit those 80,000+ words proof read, edited, formatted and submitted, the one thing you no longer have on your work is perspective! Your supervisor/s also by that point know your work so well they are not always able to spot the obvious gaps either – they too begin to read between your lines. Due to their own research interests and expertise my examiners picked up on things I had felt relatively minor and never asked me about what I thought was key to my whole argument. From this I was left with the realisation that when I think I am being clear about what I want to say, I am obviously not – also like most PhD students I was also trying to say too much.

In the final part of my viva when I was given the outcome and feedback I was so spent that I asked to record the comments on my phone. I had gone beyond being able to concentrate by this point and just wanted to go home and hug my children. This turned out to be a great on the spot record which also included the really positive comments given at the end – now whenever I feel down or receive a paper rejection I have a soothing audio therapy of two established anthropologists telling me my work is original, appealing and my arguments impressive – it works a treat!

The recording also enabled me to begin work on my corrections straight away, which for me was necessary – the planning part at least. It was a way of winding down from the viva prep stress and helped me deal with the confusion of feeling elated and concerned at the same time. When I received the written comments a week or so later I was able to take them in my stride because I knew what to expect and had already begun working.

It was difficult having to explain to nearest and dearest that yes it was over, but not quite. We had all seen the viva as the end point – the day that Mummy returns to casa and earth! So this was difficult to negotiate at first but good for me who was never quite ready to let go of the thesis upon submission.

I planned carefully, received feedback from my supervisor and took good advice from the various online sources, most importantly – STICK TO WHAT THEY ARE ASKING YOU TO DO, NOTHING ELSE… no matter how much the temptation to readdress all those things you are suddenly not happy with, don’t do it. If the examiners didn’t pick up on those things it’s not important – save it for a conference paper or journal paper where you can exercise your demons and reach a compromise with yourself. After all, more people will read a published article or hear a conference paper than will ever read your thesis.


We need to talk about … Corrections part 1

15 minute #AcWri day 4

This is a post that was written in my head a few months back, though I knew that some space between doing and handing in my thesis corrections would be necessary before I sat down to write.

I defended my PhD thesis at the beginning of the summer and have to say it was a very positive and encouraging experience. I felt prepared and both terrified at the same time, I got so nervous the day before that I was almost sick and had nightmares about it for weeks before. On the day my examiners were amazing they brought out the best of my arguments and picked up on things I had not even thought about too much – in a constructive way. Needless to say they did not ask me any of the questions I had prepared for and after nearly two hours of defence I was sure I had passed but not without some type of corrections.

I had the few weeks in the lead up to the viva reading my thesis, finding over 50 typos! And talking to colleagues about their varied experiences and listening to the mega helpful Viva Survivor podcasts run by Nathan Ryder (@DrRyder). Listening through the different ways in which people had prepared for and defended their vivas so really helpful in dispelling myths and making me think more pragmatically about it as a process. The most helpful podcast I listened to was an episode featuring Dr. Fiona Whelan about significant revisions and what it feels like to do them. I realised that this is a topic many people like to shy away from. They always seem to say they passed and then just casually brush over the correction part – no-one wants to talk about corrections!

Together with the sage advice of my supervisor and various podcasts and gratefully honest blog posts I began to view the viva as a the opportunity to have a captive audience with the few people who would ever actually read my whole thesis. Understanding that it was in their interest that I pass with a thesis that I could be proud of I also prepared myself for the inevitable corrections. There was no way I was going to get away with a straight A pass, it’s just not in my nature! I had spent the last of my savings hiring a proof reader so that I could feel safe in the knowledge that my corrections would be content rather than punctuation based (yes despite the 50 typos I later found!). I told my self that at least if they were content based it would be something I could wrestle with and find resolve – unlike my lifelong battle with commas and semi-colons.

I passed with a Bi category which at my institution means revision and re submission with no further oral exam. My examiners explained to me that the corrections were such that they could not be done on the 4 weeks turn-around required of the Ai pass – they reckoned it would take about 3 months in total. They were right it did …

And next post I will explain how it went and how I found a way to enjoy my corrections …