From infantilization to body-territoriality: Birth centers in Mexico
Birth centers in Mexico1
Introduction: Hospital birth in modern Mexico
Imagine that you are about to give birth; a desired, planned baby. You are expecting only that the baby be born well, and that you will be fine, too. You enter the hospital and have to comply with the whole protocol: your partner and family have to say goodbye to you at the hospital door. In the birthing room, the nurses will not even look you in the eyes. Instead, they dress you with a poorly fitting hospital gown; they shave your pubic hair; and they refer to you as "the tummy.” They do not allow you to move. If you complain, they call you weepy. Everything around you is insensitive, and there is no privacy anywhere. You are surrounded by other women just like you— all alone, just about to give birth, vulnerable and treated like "patients,” who are not supposed to complain. You are expected to follow the medical orders. But it is difficult to evaluate all this right now. You are exhausted, in pain, about to give birth, alone, cold, thirsty, unable to move, obliged to remain on your back in the bed, unable to speak more than to plead that it would be over soon, even if it is at the cost of more intravenous oxytocin and an unnecessary tear in the perineum. They do not allow you to be with your newborn immediately. They hand your newborn over to you when they get tired of your pleas. Nobody will help you to breastfeed. A family member can accompany you for a couple of hours, and they ask him or her to leave when a doctor comes in to check you with his team of students. The only thing you desire is to get back home soon, to the warmth of your loved ones.
This is the best-case scenario for what happens in any public maternity hospital in Mexico.
The history of healthcare in several Latin America countries, including Mexico, exhibits a particular balance of care provision, in which parts of the populations have depended on midwives for healthcare. These midwives continue to have an important role in rural and/or Indigenous contexts. This type of midwifery, usually called “empirical” or “traditional,” is not limited to attending births: it is also a resource for general healthcare in places where geography and social vulnerability constitute factors of exclusion. Thus, despite determined campaigns to end this kind of ancient midwifery, now often seen as outdated, these midwives continue to exist where they are sorely needed (Sánchez and Laako 2018).
In Mexico, midwives are also found in urban contexts working in new spaces of care. This chapter focuses on these midwives, and these particular spaces. In contemporary Mexico, this urban birthing option is a recent evolution. As explained by the historian Ana Maria Carrillo (1999), professional midwifery training programs were gradually closed down in the mid 20th century, for reasons related to the federal state’s desire to obey demographic policies dictated by the global economy and to obstetricians’ desires to gain control of birth as a source of income.
The state, in accordance with the prevailing economic interests, directly influences how many children women can have, and when feminine reproduction ought to take place. Currently, these issues are also tied to the question of how and where. At the beginning of the 20th century, Mexico promoted high fertility as a response to the depopulation suffered in the aftermath of the Mexican Revolution (1910 1920) and the Cristero War (1926-1929). In this way, from 1928 to the beginning of the 1970s, the discourse on population focused on promoting fertility, endorsed by the country’s first population laws. For example, the first Population Law in 1936 (CONAPO 1937) sought to consolidate the nation by supporting very early marriages of prolific families (Sanchez-Ramirez 2016, 23-24).
The second General Population Law, in 1947 (CONAPO 1948), was based on the same principles as the previous one, and made marriage legal for women of age 14 and men of age 16. The same law also promoted the reduction of mortality, legal protection of childhood, improvement of children’s diets and hygiene in the home and workplace. This law also prohibited any kind of promotion of contraceptive products and their supply (Sánchez-Ramirez 2016, 25-26).
The legislation related to population fostered a pro-natal society, outlawing abortion since 1937. These pro-natal measures translated into one of the world’s highest population growth rates during the mid 20th century. As a consequence, the Mexican state then needed to change drastically to a fertility reduction stance (Sánchez-Ramirez 2016, 25-26).
In Mexico, the process of hospitalization of births has advanced simultaneously with these policies. So has the positioning of modern obstetrics—a positioning which has to do fundamentally with displacing midwives from attending births (and the closing of midwifery training schools) in the beginning of the past century. Births were increasingly placed in the hands of medical and obstetric professionals, who were predominantly male. At the same time, the place of birth transitioned from the birthing mother’s own home or a midwifery center to a hospital or clinic, in rural as well as urban contexts.
In 1973, the third Population Law was decreed in Mexico (CONAPO 1973). Generally speaking, this law continues to be valid. The law endorsed the free supply and use of contraceptives, combined with a forceful campaign
From infantilisation to body-territoriality 103 to promote the benefits of having few children. Simultaneously, the plan ensured the availability of maternal and infant care in hospitals and public health centers, as part of the interest in improving the population’s conditions. However, this emphasis on hospitals and public health centers also implied control over the bodies of women of reproductive age as “captives” of international family-planning populations for low-to-middle-income countries (LMICs).
This control and condition as “captives” is simultaneously tied to where, and with whose assistance, to give birth. In the 1970s, many women in urban as well as rural areas of Mexico still gave birth at home with family doctors or midwives. However, when the third General Population Law came into effect, along with Mexico’s aim of reducing the rate of population growth via use of contraceptives, the state needed to push births into hospitals. In effect, the discrediting of midwifery care escalated (Sanchez-Ramirez 2015; Sanchez-Ramirez 2016, 23-33).
In Mexico, as in many other parts of the world, hospitalized births have been considered a public healthcare achievement. In 2018, 2,162,535 births were registered in the country, of which 89% had taken place in a hospitalized space. Only 4% were attended by midwives (INEGI 2018).
In the case of Mexico, however, hospitalized birth cannot be considered safe: obstetrics-gynecology (Ob-Gyn) has become the specialty about which the greatest number of complaints are received by the National Commission of Medical Arbitration (Comisión Nacional de Arbitraje Médico (CONAMED) 2012). According to CONAMED (2012, 8), "[Gynecology and obstetrics] is the specialty that is the most related to permanent damage or death when associated with bad practice.”
Furthermore—again in Mexico—documentation of medical practices and interventions during birth continues to mount (e.g. Cárdenas 2002, 2014; Sánchez-Bringas 2014; Castro and Erviti 2015; Organización Mundial de la Salud 2015; Márquez-Murrieta 2019). Most notably, almost half of all babies are born via cesarean section (C-section): “In the period between January 2009 and September 2014, from each 100 births, 46 were born by C-section and 54 vaginally” (CONAPO/INEGI 2015).
As mentioned above, this process of medicalization and hospitalization of birth converges with the federal state’s intention to control fertility, because attending births in medical institutions transforms women from mere consumers of maternal healthcare into captives of the state family-planning aims. This transformation has directly affected the bodies, consciousness and sexual and reproductive health of women in general.
The Committee on the Elimination of Discrimination against Women (CEDAW) has reported that, globally, many women are considered as instruments to achieve birth or of medical control, including via sterilization against maternal consent or even awareness (CEDAW 2012). This is especially the case with women in particularly disadvantaged conditions, such as young, Indigenous, illiterate or economically marginalized women, or those withmany offspring. Such procedures can only be performed in hospitals, and also need to be captured within the official health system in order to accomplish the demographic aims of the nation-states. In this respect, the nation-states are not respecting the body-territoriality of their feminine population.
The concept of body-territory (cuerpo-territorio) arose during the past two decades. It has been developed in Latin America as a way of both theorizing and working in practice within the Latin American feminisms. The concept is particularly focused on violence against women, which is fundamentally written in their bodies. This violence has a geographical place, and is intersectionally traversed. Thus, the concept of body-territoriality enables women to deal with the violence they have suffered, and with their bodily experiences, both geopolitically and in terms of their gendered conditions. For example, scholars researching forced disappearances in armed conflicts in Latin America and the increasing femicide2 in Mexico have used this concept to explain in greater detail the violence directed at women’s bodies (Gargallo, 2012; Federicci 2014; Belausteguigoitia and Saldafta-Portillo 2015).
In this chapter, the concept of body-territory is used for the first time in the frame of gender and health to discuss maternal health and care in Mexico. According to Giulia Marchese (2019), the body-territoriality or body-territory can be defined as follows: “The body of each woman is what permits her to experience the world, an experience that is structurally marked by selective violence and parametrized according to sex/gender, race, skin color, age, nationality, and class-condition.”
In other words, in this chapter I argue that the notion of body-territoriality encapsulates the fact that not all women are treated the same way within the world’s systems of sexual and reproductive healthcare—especially maternal healthcare. The treatment received depends upon the prevailing gendered culture, which goes hand in hand with economic, medical, democratic and political resources related to equality in each country.
In the case of Mexico, the “change of scenery” in terms of how and where to give birth has displaced birth practices from the sphere of women and their midwives, who used to share their knowledges and empowerments about the feminine body, toward the expropriation of women’s bodies and of midwifery knowledge as a result of the hegemonization of modern Ob-Gyn culture. Both elements (how and where to birth) fall back on to the body that reproduces life: that of the pregnant woman.
To analyze Mexico’s birth centers and their relationships to women’s bodyterritoriality, this chapter will first outline the Mexican context—a knowledge of which is crucial to understanding the resurgence and importance of birthing spaces that are not hospitalized. These spaces are called casas de parto—literally, “houses/homes of birth,” but in English usually referred to as “birth centers” (BC). The chapter then explains, briefly, the situation of BCs globally before describing the methodology of the research in its health and gender perspective. I then demonstrate the characteristics of BCs in Mexico; the services they provide; and their legal context. To illustrate the importance
From infantilization to body-territoriality 105 of BCs in Mexico, I analyze the practice of “giving birth differently,” while building on mothers’ voices and experiences of “humanized” or “conscious” births. Finally, the chapter concludes that, in a context such Mexico’s, where a persistent abuse of authority over gestating women’s body-territoriality exists in the form of modern Ob-Gyn, some women nevertheless do seek to give birth differently. In the BCs, they find a space for that and care that allows them to manifest emotional and bodily empowerment through birth—an empowerment that is an affront in countries where women are expected to be submissive to the hegemonic, macho medical power.