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.

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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.

 

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

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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)

fish-swimming-against-the-stream

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!

Reading: 

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.

Email:

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.

Editing:

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!

stock-photo-13906320-finish-line-ahead-on-yellow-road-sign

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.

examsover