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Entre Semana: Thurs, May 19
A look at maternal health in Mexico
Welcome to another edition of Entre Semana, a space where I dive deeper into topics I am passionate about.
In today’s newsletter, I explore maternal healthcare in Mexico, particularly how improved metrics in some areas (maternal mortality) have not translated into broader access to dignified, conscientious care during labor and delivery. I will come back to this subject soon to evaluate the current state of abortion rights in Mexico and the impact this has on reproductive health.
I have linked directly to sources in the body of this essay and I hope you take time to explore them.
“Dar a luz”—“to give light”—is the literal translation of “to give birth” in Spanish. It has always struck me as a poetic phrase for a primal experience, hovering on the border between transcendence and euphemism. In Mexico today, too many women experience it as the latter.
According to data from a survey conducted by INEGI (National Institute of Statistics and Geography) in 2016, one in three Mexican women experience obstetric violence, defined as any action or negligence by healthcare professionals that causes physical or psychological damage during pregnancy and labor. This can range from verbal abuse and discrimination to being subjected to caesareans, episiotomies and sterilization without consent. “When people talk about maternity, rarely do they mention that becoming a mother can imply suffering from tremendous violence during what is, for many women, one of their most vulnerable and frightening moments.” Women birthing in public hospitals are twice as likely to suffer the trauma of these violations of their rights and dignity.
Prior to the pandemic, Mexico’s maternal mortality ratio (MMR) had been in decline for nearly two decades, dropping from 55 to 33 per 100,000 births from 2000 to 2019. In 2020, the MMR increased to 46.6, with 25.4% of those deaths linked to COVID-19, and the remainder likely attributable to reduced access to preventative care and health services. Data appear to indicate the same comorbidities in pregnant women as in the general population led to deaths caused by the virus—obesity, hypertension, diabetes—revealing the depth of public health inequities and how they reinforce each other in poorer demographics. In 2020, the U.S. MMR was 23.8 per 100,000 and was also unevenly distributed across the population. Black women were 2.9 times more likely to die in childbirth than white women in the same year.
To public health experts, the MMR is useful to demonstrate a nation’s progress with better care in hospital settings. Of course, improved public health and sanitation have been critical to reducing mortality for mothers and infants, and should be celebrated as landmark achievements of the 20th century. But as laboring mothers continue to struggle, even in wealthy nations, it is important to look at other metrics: clearly, hospital births are not a risk-free solution.
Mexico has a caesarean section rate of 46%, significantly above the upper limit recommended by the WHO (10-15%). I remember being asked frequently while pregnant if I was going to have a c-section, which I couldn’t answer since I only anticipated it would happen in an emergency. But for many women in Mexico (and elsewhere), the scheduling of c-sections is a choice made long ahead of their due date, encouraged by doctors who present it as an easier, less painful option and may also downplay the risks. Poor and indigenous women are often subjected to c-sections as if they have little choice in the matter, and with scant justification on the part of the doctors.
“The pressure they are under in public facilities, where they are overwhelmed and need to literally ‘dispatch’ one woman after another, means many unnecessary c-sections are performed, because they are in a hurry,” notes Dr. Roberto Castro, a researcher from UNAM. The WHO is clear that c-sections save maternal and infant lives, but also states that “caesarean sections can cause significant and sometimes permanent complications, disability or death particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery and treat surgical complications. Caesarean sections should ideally only be undertaken when medically necessary.”
Working in quiet but tenacious resistance to this industrialized model are the midwives, or parteras. “We're doing what the health system doesn't,” says a traditional midwife in Guatemala, interviewed for a National Geographic article. “We work more than the doctors, and we’re the ones helping women. Midnight. 1 a.m., 2 a.m., at any hour. When they call...you have to go to the patient.” In many remote communities, the role of traditional midwives is still valued and revered. Their presence, accompanying women and their families throughout pregnancy, creates deep bonds of trust and saves lives. Midwives are often the ones to convince a high-risk mother who is fearful of hospitals that she must seek medical care.
“If you want to change the world, you should want to change how we are born,” says midwife Rafaela López in the documentary film “Birth Wars”, which beautifully chronicles the chasm of distrust between doctors and midwives, and the stories of laboring women in between. “Birth should happen in an atmosphere of warmth, harmony, love, and peace.” According to data from 2010-19, only 6% of births in Mexico were attended by midwives and in 2019, 89.6% of Mexican births took place in hospitals.
Doctors and public health experts all over the world have increasingly recognized the value of midwives and doulas as partners who can support better outcomes for mothers and infants, and official recommendations have gradually been modified to prioritize vaginal births, skin-to-skin contact, delayed cord clamping and other more “natural” practices.
Medical hubris has led to grievous errors in the past. A Hungarian physician named Ignaz Semmelweis (1818-65) once set his mind to solving the problem of puerperal fever at Vienna General Hospital, where doctor’s wards suffered three times the number of maternal deaths compared to midwives’ wards. Anecdotes tell of pregnant women choosing to risk a “street birth” rather than be admitted to the hospital. Semmelweis hypothesized that the women were contracting infections spread by the doctors, who did not wash their hands routinely between patients. He was roundly ridiculed for an idea whose time hadn’t yet come: Louis Pasteur’s germ theory would not come on the world stage for another twenty years. Semmelweiss died from a gangrenous wound two weeks after he was committed to an asylum in 1865 and would only be vindicated posthumously as the “prophet of bacteriology.”
When I was pregnant with my first child, I did all the reading, research, wrote and re-wrote my birth plan: letting my left brain go wild. But now, ten years later, I can see that in the constellation of advice, two stars were all I needed to navigate. Both were pointed out to me by midwives.
One came from a book by revered midwife, Ina May Gaskin: “let your monkey do it”. Live birth is an experience we share with many other animals, though evolution did take a gamble on “giving light” to homo sapiens. Our larger brains required larger skulls, and the passage through the birth canal is a daring physiological feat. What I felt in Gaskin’s words was an antidote to over-thinking, a reminder that instinct and body awareness can take over.
My second navigational tool was an image: a journey down a river as metaphor for the final stages of labor. The midwife and teacher who shared this made it clear that for this part of the journey, I may need to be let go, to go alone. By then, I might not be reached by anyone on shore: questions, recommendations, even words of comfort, might not be heard.
Birth, like death, is a spiritual encounter we all experience and reducing it to procedures, data, and efficiency will in the end leave us all impoverished. “When I talk about Birth Wars, people think it’s a story about motherhood and it’s not. It’s essentially a story about human rights. Others say, ‘oh, this is a women’s issue’ and I say yes, but it is an issue for men too,” noted filmmaker Janet Jarman in an interview about her documentary.
“To be a midwife, you have to feel it in your blood,” says Rafaela in Birth Wars. “I am going to welcome a human being to the world…it’s no small thing.”