Human rights in development, women’s rights in childbirth: What about the women in the Global South?

Reproductive rights can be considered part of the newer generation of rights. In human rights literature, political and civil rights are usually considered the first generation of human rights, whereas the second generation focuses on rights related to equality. The third generation of human rights is more involved with identity and “soft laws”—laws that are passed to defend particular principles, such as women’s rights to be free from obstetric violence, yet are rarely enforced (Kuokkanen 2012). Generally, statements about reproductive rights are not binding and are among the most disputed rights at national and global levels. These politicized issues include abortion, birth control, freedom from coerced sterilization, protection from female genital mutilation and access to good-quality healthcare, family planning and education on sexually transmitted infections. Various chapters in this book have made reference to these politicized rights in terms of midwifery, as well.

During the 1990s, reproductive rights became closely engaged with women’s rights (Cornwall and Nyamu-Musembi 2004; Cornwall and Molyneux 2006). They were especially bound to the global campaign on making violence against women visible, bringing on to the agenda issues such as sex trafficking and rape as a tool in wars. According to Keck and Sikkink (2000),

Post colonial midwifery 179 the campaign raising the issue of violence against women developed one of the most successful transnational advocacy networks, not only in terms of including women’s rights in the human rights agenda but also in uniting disparate groups of women from the Global North and Global South in a global women’s movement, as exemplified and enacted in the international conferences held by the organization Women Deliver. Indeed, these authors note that the campaign raising the issue of violence against women consisted in part of a series of international conferences that enabled agenda setting and networking (among others, Cairo 1994 and Beijing 1995). Since this 1990s “gender mainstreaming,” however, the issues of reproductive rights and women’s rights have stagnated as a result of stronger political divides related to political and ideological struggles (Cornwall and Molyneux 2006).

Reproductive rights’ origin in reproductive health has been closely linked to development policies, particularly to issues of population control (Hartmann 1999, see also Chapters 3 and 4). Initially, reproductive health policies were characterized by top-down approaches and the lack of a human rights perspective, particularly in many family-planning programs, which increasingly became subjected to women’s health activists’ criticism, especially during the 1984 United Nations (UN) World Population Conference in Mexico City (Hartmann 1999; Keck and Sikkink 2000).

In fact, given this background, characterized by coercive population control methods, for many women in the Global South, Indigenous women and for people of color in the Global North, “reproductive rights” as a continuation of earlier reproductive health policies in population control appear dubious. As noted in Chapter 2, instead of reproductive rights, scholars of color prefer the term “reproductive justice,” which implies taking into account these previous coercive population control methods, including forced sterilizations (Luna 2009; Craven 2010). The proponents of the reproductive justice frame argue that, while reproductive rights have been won for affluent, middle-class White women, simultaneously those same rights have been diminished for women of color and women from lower-resource countries. Thus the particular cultural and ethnic contexts and differences play an important role in the interpretation of reproductive rights, often downplayed by Western feminists. According to some reproductive justice activists of color in the USA, the reproductive justice framework emerged in 1994 with the objective of bringing together notions of reproductive rights and social justice. As an intersectional theory, it highlights the lived experience of reproductive oppression in communities of color and expands the narrower focus on legal access and individual choice to a broader analysis of racial, economic, cultural and structural constraints.

In this sense, the tensions involved in reproductive rights issues are not only related to the increasing emergence of Islam on the global stage and to a growing degree of religious orthodoxy and conservative ideologies, as often argued by scholars in defense of reproductive rights, but also to thevery concrete and historical experiences of reproductive politics in action in different locations of the world and among different populations (Cornwall and Molyneux 2006).

One of the cornerstones of reproductive rights is maternal health and childbirth. The integration of a human rights approach into the sphere of development and reproductive health in terms of maternal health is a significant achievement in itself. The UN adopted improved maternal health as part of the Millennium Development Goals, viewing it in terms of sustainable development and gender equality in order to diminish maternal mortality (Ban Ki-moon 2010; Sarelin 2014a).

However, despite the advance of integrating maternal health into development agendas as a priority, a clinical, Western view continues to dominate: it is generally understood that, in order to diminish maternal mortality and to improve maternal health in low-resource countries, these countries must be provided with “improved,” Western-style medical systems (Rosenfeld and Maine 1985; Sarelin 2014a). The dominating perception is that the problem with Global South or Indigenous territories is that women do not have sufficient access to clinics and hospitals or, for one reason or another, do not go to them in emergencies. Therefore development policies on maternal health continue to emphasize methods of transport to clinics and hospitals to give birth, or other means of increasing access to clinics and hospitals. Additionally, there has been a strong focus on providing finances to improve obstetrics and high-technology sub-specialties to tackle emergency situations in maternal health.

While it goes without saying that having access to quality care is an important human right, this dominant clinical view of reproductive rights in maternal health contains some key problems. First, the pending “problem” continues to be to get women to these clinics and hospitals. Indeed, there seems to be a neglected issue as to why many women in developing countries, even when possible, will not attend clinics and hospitals but might consult their community “TBA” instead. This, again, enters into the arena of reproductive justice: many women feel they receive bad, even abusive, treatment in these facilities. There are also indications at local levels that the politics of prioritizing hospitalization in childbirth has created a situation of facility saturation, causing poor-quality service or a lack of service, resulting not only in increased use of cesarean sections but also in increased maternal mortality (Penwell 2010; Freyermuth, cited in López 2013; see also the Introduction of this book).

Another dominant clinical approach to maternal health and reproductive rights has been the displacement of “TBAs.” In the case of Mexico, this principally refers to Indigenous midwives. Argüello and Mateo (2014) extensively explore international politics dealing with birth attendants, especially traditional ones. They note that it is not until fairly recently in human history that births have become considered pathological rather than natural, meaning that births have been transferred from women’s traditional care into the sphere of Western biomedicine. This has often entailed the disqualification of traditional midwifery, since that type of midwifery care has been characterized by the empirical understanding of births in a natural physiologic manner, in contrast to the medical view of birth, which emphasizes risks. This second, problematic aspect of the dominant, clinical perception of reproductive rights can be understood as the right of women to qualified medical care, and even more so as to “enable” women in the Global South to have the same right to obstetric care in pregnancy and birth as in Western countries (Rosenfeld and Maine 1985; Sarelin 2014a).

Until the 1990s, according to Arguello and Mateo (2014), global politics on maternal and child care, especially after the declaration of Alma Ata (1978), took into account the need for all resources to be used to safeguard maternal and infant health, especially in developing countries. This politics tried to integrate traditional midwives in maternal care by capacitating them as a source for health services in remote areas. However, since the 1990s, international organizations have shifted their discourse to favor a similar type of development to that found in Europe and the USA. This has benefited the Western-style medicalization of birth, medical practice as a profession and the requirement for university education. What this implies, argue Arguello and Mateo, is a conflict between traditional midwives and the official healthcare system, in which Indigenous and rural women face a Western, masculine medical specialty that many of these women reject for various reasons; among them are racism and obstetric violence, massive overuse of technological interventions and non-consensual sterilization or obligatory contraceptive methods such as the unconsented placement of intrauterine devices (IUDs).

Yet, in the past few decades, a key shift has taken place in terms of international politics in maternal health: now there is a stronger preference for births being attended by professionals called “skilled birth attendants” (SBAs). This new focus implies, first, that traditional midwives, who lack official certification, as previously explained, are definitely excluded from the official maternity care system. Second, and in contrast, this international political decision has started to benefit professional midwives (UNFPA 2014). International organizations such as the WHO and the UN calculated several years ago that they need at least 350,000 more SBAs, mostly qualified professional midwives, in the Global South in order to diminish maternal mortality (ibid.). This call for SBAs constituted a significant turning point for the world’s midwifery organizations, particularly in the Americas, where midwifery had been largely eliminated with the rise of the modern biomedical system. (To contrast, consult for example, Chapter 1; Marland and Rafferty 1997; Davis-Floyd and Johnson 2006: 32-38).This call might imply that, in the course of time, midwifery will come back from its positioning as an underdog of the official healthcare system. However, this also implies a potential, growing tension within and between the so-called skilled, professionalized midwives and the traditional, empirical midwives, not only because the traditional midwives feel threatened but also because the essence of midwifery has long been so strongly based on empirical knowledge, not academic qualifications. Nevertheless, as Sarelin (2014a) notes, professional midwives have often joined doctors and obstetric teams in the attempt to eliminate traditional midwifery to gain professional recognition for themselves.

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