Reproductive Health Disparities: A Harsh Reality

Kris Holloway’s story, Monique and the Mango Rains, tells of her two years in Mali working as a Peace Corps volunteer. Holloway works closely with Monique Dembele, the sole village midwife and general healthcare provider in Nampossela, a small, remote, rural village. What stand out to me from her experience are the systemic, structural, social, and cultural circumstances that force the village women into perilous health positions, particularly pertaining to pregnancy and women’s health issues. The shocking fact is that the women in Nampossela have virtually no control over factors that directly and negatively impact their lives and health outcomes. This is very much like the inhabitants of Flammable, an urban shantytown in Buenos Aires, Argentina, whose children have strikingly high rates of lead poisoning, simply because of where and how they are forced to live. It seems that in the 21st century, this circumstance ought not to exist anywhere on our planet—so, how can it be that this is the reality for so many women and children?

 

Take, for example, the story of Korotun, a village woman who is beaten repeatedly by her husband (Holloway 2006: 53). Korotun believes that if she can get pregnant, her husband will not be so angry with her, so he will not beat her. She has no way to protect herself from the beating, and the harsh reality is that another pregnancy might not ameliorate her situation.

 

Or consider the example of Oumou, who has lost four children out of nine. She cannot bear to have more children for fear of them dying, so she wants a form of contraception. But her husband will not allow it. He would refuse to use a condom, and would not allow her to take oral contraception, forcing her to obtain and swallow any pills in secrecy.

 

Third, consider Bintou, a village woman who passes away after the birth of her seventh child. Holloway points out that the factors that caused Bintou’s death are manifold. It was the rainy season, so she could not give birth in the village’s dilapidated birthing house. Bintou might have been malnourished, or she might have suffered from malaria. Or maybe, Holloway hypothesizes, her uterus could not handle a seventh labor. The list goes on. Whatever the cause, these were all circumstances out of Bintou’s control. Had Bintou known how critically important sufficient rest was for the safety of her seventh pregnancy, perhaps she might have tried to rest. But how could she have known? Her uninformed husband would not let her rest from work because of the prevailing cultural norms and economic need for Bintou to help out at home and in the fields. Her husband did not even let her see Monique for a prenatal consultation, Holloway assumes. So Bintou did not have any much-needed advice about prenatal care.

 

All three of these women suffer from structural violence—the prevailing social, political, economic forces that directly impact personal, individual health (Farmer 2013: 9). They are victims of this violence with severely limited ways of protecting themselves. Korotun is not choosing to get pregnant because she wants another baby, but rather because she wants her husband to stop beating her. (In addition to being beaten by her husband, Korotun will now have an unwanted daughter.) Bintou of course did not want to die during labor. Despite Monique’s best efforts, these women had none of the knowledge or access to resources that could have prevented these adverse health outcomes because of the culture, society, and economy in which they live. Similarly, the residents of Flammable did not choose to live on top of garbage and toxic waste dumps—where children and pregnant women would be exposed to high concentrations of heavy metals. But they had no other choice.

 

But there is good news. Researchers all over the world are working to design innovations that can create lasting change. For example, an injectable contraceptive that lasts for 3 months has been introduced recently in Burkina Faso (McNeil, 2014). As Monique explains to Holloway, villagers love injections, because they “represent the pinnacle of Western medicine, and Western medicine is good” (Holloway, 7). Perhaps this will be a sustainable solution, which would allow women to use contraceptives with less of a risk that their husbands may find out.

 

My older sister had a baby this past summer, and her most difficult decisions during her pregnancy were whether or not she should choose organic, non-GMO foods, or which of many options was the best stroller to buy. She could take endless prenatal supplements, and had months of maternity leave to look forward to. The women of Nampossela could not fathom these options. While my sister’s experience certainly was not universal throughout the US, the disparity between our privileged existence in the developed world and the Malian women’s experience could not be more stark.

 

 

Discussion Questions:

I’m interested in the same question regarding Bintou’s death that Holloway poses on page 89: “If Monique had had access to more emergency medical care, could she have saved Bintou?” Monique successfully delivers so many babies with such simple tools—would investing in high-technology care be “worth” it? Would it be better to put resources towards other aspects of healthcare, such as malaria or HIV/AIDS prevention? Even if they were able to create a more hospital-like setting in Nampossela, would the villagers welcome the change, considering their cultural values that make their childbirth experience much different from the experience we are familiar with?

 

Who is responsible for these complex, multi-faceted problems? Who can help? Holloway, as a Peace Corps worker, certainly helped for the two years that she was stationed in Mali. And, there’s evidence that her and Monique’s work is making a difference: the number of women coming in for prenatal consultations has steadily increased over time (Holloway, 94). But will her work make a lasting impact? What kind of help would make a lasting impact? Will the village’s maternal health deteriorate again after Holloway’s two years there?

 

 

References:

 

Auyero, Javier and Debora Alejandra Swistun. 2009. Flammable: Environmental Suffering in an Argentine Shantytown. New York: Oxford University Press.

 

K. Holloway. 2006. Monique and the Mango Rains: Two Years with a Midwife in Mali. New York: Waveland Press.

 

McNeil, Donald. “New Contraceptive Shot Being Released in Africa.” 14 July, 2014. http://www.nytimes.com/2014/07/15/health/new-contraceptive-shot-being-released-in-africa.html?_r=0

 

P. Farmer, A. Kleinman, J. Kim and M. Basilico, eds. 2013. Reimagining Global Health: An Introduction. Berkeley: University of California Press.

14 thoughts on “Reproductive Health Disparities: A Harsh Reality”

  1. Lindsay,

    I really enjoyed your post. Your comparison of the experiences of many of the women of Nampossela who are oppressed by structural violence and the experience of your sister this summer was very striking.

    You raise the issue of the lack of “women-centered” birth control options, such as the injectable contraceptive, that could potentially empower women by giving them more control over their sexual relationships (Farmer raises this issue also in Infections and Inequalities). While I think this technology could provide more options for women in Nampossela, I do not think this is a lasting or sustainable solution to the structural violence that oppresses women. In order to truly create sustainable change, we need to examine why women lack agency in specific communities and to address those root causes of gender inequality.

    In response to your first discussion question, I think that the villagers of Nampossela would welcome any technology that could make reproduction safer, less painful, and more in the hands of women. Access to high quality medical care as a human right transcends cultural differences. I also find Allison’s argument compelling (https://blogs.brown.edu/anth-1310-s01/2015/09/23/technology-vs-tradition-the-role-of-midwives-in-modern-births/). Broad developments in living conditions such as improved sanitation and nutrition might contribute to sustainable positive change in maternal health.

    Thanks,
    Mira

  2. Lindsay, I appreciate your focus on maternal and infant health. I like that you compared your sister’s worries during pregnancy to those of the women in countries like Mali. I agree that there are great disparities and it is a problem that makes life much more difficult for people in other countries. The same goes for many different problems that are occurring in developing countries such as Mali. There unfortunately is not any one thing that can be done to solve these problems.

    Programs such as the Peace Corps, Unicef, etc. are in place to make advancements on solving these problems. Programs can bring resources, or Western ideas into these countries to help build them up. Unfortunately, just as you asked in your discussion question, I think that many of the problems will continue after people like Holloway leave. I do, however, believe that advancements will be made and the village will probably be better off than they were because they are better educated now and they will stick with some of those ideas; while others may fall back to the way they were. One of the major problems that these countries face is that they have been living this way for so long that they are used to this way of life, and in some ways it is a part of their culture. I believe that they can definitely learn from the people who come, such as Holloway, and make certain advancements in their lifestyle and way of life. So while they will not by any means be completely westernized because they lack the resources, they will be better off than they were before anyone came with Western ideas and resources.

    1. I would push back a bit against the idea of Western ideas being brought in to “advance” lifestyles in rural Mali… While it’s true that Halloway was able to bring in resources to improve the quality of maternal care in Monique’s village, it was really Monique and the local women who were responsible for administering the care. Halloway did little in the way of changing practices, she was just able to use her financial and political power as a white American to bring in funding that made Monique’s efforts more effective. I’m also a little uncomfortable with the idea of “advancing” poor, rural African societies, as this falls into a logic of cultural and societal hierarchy that separates “traditional” societies from “modernized” societies, and places a moral judgment on their “culture”. I think it can be more helpful to look at it as improving health measures and quality of life. I also think it’s important to recognize the contributions of people within these communities (like Monique) to improving their health systems/quality of life… it is not always imposed or “donated” from outside. Additionally, sometimes well-intentioned Western interventions backfire, so it’s hard to say that the influence of Western ideas and resources is always a good thing.

  3. Lindsay,

    I very much enjoyed your post and think you did a good job illustrating the various issues surrounding reproduction faced by the women of Nampossela as described by Holloway. I’d like to respond to your first discussion question, specifically: “If Monique had had access to more emergency medical care, could she have saved Bintou?” Monique successfully delivers so many babies with such simple tools—would investing in high-technology care be “worth” it?”

    Firstly, I’m not sure there is any way to know if Bintou could have been saved with modern medical technology. As you pointed out, Holloway speculates that Bintou could have been at especially high risk for complications due to malnourishment, fighting a malarial infection, or because of her high number of previous births. Any, all, or none of those factors could have contributed to Bintou’s death, but I believe she would have undoubtedly had a greater chance of surviving if she had had access to advanced medical interventions. Nonetheless, I think it’s important to note that even if a medical intervention during the birth could have saved her life, the underlying issues of her high-risk situation remain. Thinking back to McKweon, one is reminded that a society can only get so far by applying a medical solution to a structural problem. With this in mind, I believe that while the community would undoubtedly benefit from immediate access to high quality medical care, the underlying structural issue cannot be left unaddressed.

  4. Lindsay,

    Your examples of the different gender inequality issues all of these women faced are really interesting. Although each one is different, they all boil down to fundamental inequality based on sex. In regards to your first question, I think that more advanced medical technology in delivering babies would be very worth the cost. Although Monique is very important to the community and saves many lives of both the mothers and the babies, the rate of successful pregnancies both in her village and elsewhere in Africa are drastically lower than in the United States. Or, as Paul Farmer would say, why do we have to choose between allocating funding for pregnancies or HIV? Is there somewhere we can find the money to cover the costs of both?

    You also mention that the people in the village may be opposed to the new technologies because they may interfere with their cultural processes of giving birth. In my opinion, if both mothers and infants are regularly dying during birthing, the people would not be opposed to technology that could save them. In addition, in times in the book Monique and the Mango Rains, it seemed as though the villagers readily welcomed Western medicine. For example, they all really liked injections simply for the reason that to them, injections symbolized western medicine and health technology.

    1. Hi Sierra, thanks for your comments on this! I totally agree with you (and Farmer)–there should not need to be an allocation of resources between HIV treatment and pregnancies, for example. As Farmer would say, there should be a preferential option for the poor–they should not receive anything less than the best available treatment. And I agree also that since women are dying in childbirth at a shockingly frequent rate, they would likely not oppose a Western medicine intervention. I think, though, that if higher-tech health technology were to be introduced, it would be critical that there were a system set up to ensure long-term sustainability–there need to be plenty of health workers trained to deliver the necessary care and use and maintain the new technology.

  5. Lindsay,
    I really enjoyed your post and felt that the use of specific examples was particularly effective in supporting your argument.

    In response to your first discussion question, I believe that it would definitely be worth introducing high-technology into the birthing experience if it meant saving lives and alleviating suffering. In the past, both poverty and culture have been used time and again to justify lower standards of care in developing countries. I believe we must be careful when using culture to explain disparities in care between the global north and the global south. Even if specific childcare practices are deeply embedded in the cultures of these societies, these practices stem from systematic gender inequality and a distinctly patriarchal society. Culture does not mean that the women want these practices to continue, nor does it justify the continuous abuse and repression of these women.

  6. To address your first question, Creating a hospital-like setting (or just a hospital) has benefits that go beyond just the birth process, so creating infrastructure, adding high-tech care, and improving access to emergency medical care can benefit those other concerns (such as malaria and HIV/AIDs.) Basically, it can follow the “nail soup” model that Benton mentioned in her talk.

    There is, however, the issue of the translation of the technocratic model–for example, the use of pitocin to speed contractions, but no painkillers in India. So I think we should be careful about the kinds of high-tech care that we bring in, or at least to be conscious of the consequences of bringing in a more technocratic approach.

    Cultural values are based on what we know but also depend on what is available. When it comes to welcoming the change, creating trust is more important than cultural values and making conditions that favor access and trust in those who need those resources. I also really like and agree with what Alexandra said–cultural practices may be accepted and established, but this doesn’t make them justified and it doesn’t mean that women want these practices to continue.

    1. Hi Sylvie,
      Thanks for your thoughts on this! I’m glad you brought up the “nail soup” idea–I wrote this post in the beginning of the semester, before we heard from Benton, but I was thinking the same thing when she told us about “nail soup.” I also think your ideas about creating infrastructure and investing in and providing high-tech care could contribute to a diagonal approach to healthcare in Mali–I think that could be really effective.
      And I think you make good points about being cautious of what kind of care is introduced–it would be important to avoid situations such as the provision of water filters for guinea worm that don’t filter out other pathogens, or a circumstance like the one described in HIV Exceptionalism, in which there are lots of resources allocated to an disease for which they are not really needed. This is why I think the work of anthropologists is so important.

  7. Hey Lindsay,

    I appreciate your blog post and the ways in which it examines the structural violence described in Monique and the Mango Rains. Your post reminds me of Paul Farmer’s views on agency, and how agency of marginalized people is often overstated when in reality they don’t really have any other choice than what they’re doing. You raise the question of “who is responsible?” and I think the answer to that is “no one in particular,” making it all the more scary and tragic. The nature of structural violence is such that it is institutionalized and not quite tangible and there is never one person in particular to blame. You also raise the question of “who can help” and I think the answer to that is – some sort of international pressure to equalize the world. Governments wield enormous amounts of power and I think they are the best bet because only they have the ability to ensure people have rights.

    1. Hi Ria,
      Thanks for your thoughts on this. I totally agree with you–I think there needs to be some sort of international pressure to ensure that governments throughout the world provide all their citizens with health as a human right. I wonder, though, if that’s not possible? Is it too idealistic to think that that could happen? I hope not!

  8. Hey Lindsay,

    Thank you for your post! It was definitely interesting and thought-provoking. I liked the way you used specific example from Monique and the Mango Rain to discuss the structural violence that is present in many developing countries when in comes to reproductive and women’s health.

    Your questions were really interesting but also incredibly complex. I think the question of blame fall is very much frustrating because there is no specific person, organization or entity in that uniquely responsible for this problem. The structural violence is inherently diffused and impossible to pin down. I think we need to address all the factors that contribute to this level of structural violence and try to change each of the individual factors. I think your examples also very much highlights the actual violent nature of symbolic violence, the end result for some of these women was death. Farmer would argue that it’s just as bad as actually using a gun to kill someone. Although I don’t believe it is as concrete as that, I do believe the results are the same and very tragic.

    1. Hi Yilena, thanks for your thoughts! I really like your point about symbolic violence–I hadn’t thought of that. But I suppose it’s true that symbolic violence applies here–the women internalize social pressures and norms, and perhaps feel that because they are women, they “deserve” or should accept multiple unwanted childbirths, or subordination to men, or female genital mutilation. These things are so institutionalized and normalized in Malian culture. I wrote this post at the beginning of the semester, but I’ve been thinking about it now in light of the rest of the semester–maybe Mali needs a charismatic leader to begin to instigate some social change (some one like Mechai, who normalized condom usage in Thailand, as shown in the Rx for Survival episode we watched).

  9. Hi Lindsay! I thought you did a great job of highlighting the experiences of different women in Nampossela. Your summary of several people allowed me to identify common trends across how each experienced and responded to gender inequality and reproductive constraints.

    In regards to the first part of your discussion- with questions that ask whether disseminating care to particular populations is “worth it”, it is important to be cautious on how we conceptualize worth. This word, worth, has several meanings that hark back to class discussions on: 1) cost-effectiveness; 2) popular notions in the 1990’s that populations in developing nations were unable to handle antiretroviral regimens; and 3) who is deserving of quality care. In regards to the first point, Farmer would argue that it is unethical to ration money according to “need” and assign a price tag to saving lives. It is also unacceptable to deem that members of the global south cannot “handle” certain care due to stereotypes of inattention to time and poor drug adherence. Underlying these assumptions is the stoic primitive who is best suited to “no frills” care stereotype as well as paternalism, which is endemic in global health today. I appreciated the quotes that you used around the word, worth, in light of these issues.

    Despite the fact that Monique successfully delivers so many babies, higher quality care would definitely be “worth it”. Throughout the book, Holloway describes the local health clinic’s ongoing need for more standard health care products- vaccines, pills, etc. These are all basic items that prevent against conditions easily managed in wealthier countries. That being said, I’m not sure if “investing in high tech health care” is necessarily the immediate answer, as there is already a lack of basic health care infrastructure in Mali and tertiary care does not necessarily equate to better health (as lagging health measures of the United States in comparison to other developed countries indicate, despite spending “more per person on health care than any other nation”).

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