Category Archives: Section 1

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.

Technology vs. Tradition: The Role of Midwives in Modern Births

Following the commonly accepted epidemiological narrative – that medical discoveries decreased deaths from infectious diseases and increased lifespans – lower levels of mortality in childbirth are likewise frequently attributed to innovations in technology. Yet, as shown first by Thomas McKeown and later by John and Sonja McKinlay, much of the decrease in general mortality rates occurred far before vaccines or antibiotics became prevalent. More likely, people started living longer because of broader social changes such as improved sanitation and superior nutrition. Could this same misconception be true about the relationship between medical technology and childbirth? And if so, what normative positions might we have to question as a result, e.g. the superiority of doctors over midwives, hospitals over homes, and technology-heavy births over natural births?

Lately, two opposing narratives have dominated discussions of the birthing process in the news: the disappearance of midwives from developing countries as they are outclassed by doctors, and the reemergence of midwives in developed countries like the U.S where “non-traditional” i.e. non-medicalized births are rapidly increasing. Yet through these stories, the news often makes clear causal assumptions about the life-giving benefits of technology. “[Chiapas, Mexico] is poor,” Denise Grady of the New York Times writes, but describes the impact of this fact as that these women “live without cars along rough roads far from hospitals” and “often give birth at home,” at high risk for death during birth because of their lack of access to technology and reliance on midwives. Throughout history doctors have drawn similar conclusions about their relative superiority, dismissing midwives as unclean, under-educated, and reliant on primitive techniques (see Megan Vaughan).

Yet while basic technology can be extremely beneficial in the birthing process, especially when looking at the results of individual, medically-complicated pregnancies, can it single-handedly improve mother and infant health in developing countries? What about poverty, for example? As in the news article, poverty is cited in relation to lack of access to medicine and hospitals. Yet the effects of poverty on nutrition are also key for a mother’s health from pregnancy to birth to the postnatal period. What too of “physically exhausting” labor in the fields, “abundant infectious disease” and poor sanitation, and many other trappings of living poor in a poor country? All of these are factors that Kris Holloway describes seeing affect maternal health, and mortality, during her years working with a midwife in Mali – factors that IVs or C-sections alone could not necessarily alleviate (89).

In addition to the effects of general inequality on reproductive health, cultural expectations of women place them in an even more disadvantaged position in many countries. Holloway describes women in her town in Mali as lacking significant agency over when they have sex or children. Complications occur because the woman aren’t allowed to rest appropriately or end up pregnant again soon after giving birth. And the cultural phenomena of female circumcision has led to lasting effects, including an increased risk of vaginal ripping during birth – and thus severe hemorrhaging, a major cause of maternal death.

Meanwhile, well-off American women have begun voicing other concerns about hospital births, speaking out against the idea that liberal usage of modern birthing technology creates a reproductive utopia. While clearly having access to technology is preferable to not, many are now arguing that U.S. doctors overuse this technology to the detriment of women’s health – and that midwives, with their more natural approach, are a way to protect women. Holloway cites with astonishment that 25% of American births are C-sections, far above the ideal limit given the maternal/infant health complications that can result from such invasive surgery (89). And Vaughan describes how Americans, “oppressed and alienated by biomedicine,” are actually “env[ious]” of “natural” African births (24). So while we should be careful not to romanticize poverty or lack of agency, there does seem to be an argument – biological but also social – for limiting technology in births. Importantly, however, is that many of these American women utilizing midwives are well fed and far above the poverty line. The point is not that technology is bad, but rather that when the woman is already relatively healthy and economically privileged, technology often isn’t key to, or even necessary for, a successful, healthy birth.

Together, these examples weaken two major assumptions about the relationship between technology and birth: one, that technology alone can solve the problem of maternal mortality in developing countries, and two, that more technology will always be beneficial to maternal health and well-being. While there is no clear-cut answer to solving maternal mortality, my main argument is merely that a more careful definition of the cause of the problem can illuminate potential solutions. To speak broadly and reference Paul Farmer, I think it is clear that this biosocial problem needs a biosocial answer, not just a biomedical one. We should work towards providing medicine and technological help for individuals, but also social change for the population. And midwives for all women.

Articles:

Gaestel, Allyn and Allison Shelley. 2013, July 8. What is Pregnancy Like in Nepal. http://www.theatlantic.com/health/archive/2013/07/what-pregnancy-is-like-in-nepal/277287/

Grady, Denise. 2015, August 31. Training Midwives to Save Expectant Mothers in Chiapas. New York Times. http://www.nytimes.com/2015/09/01/health/midwife-mexico-chiapas.html

Santa Cruz, Jamie. 2015, June 12. Call the Midwife. The Atlantic. http://www.theatlantic.com/health/archive/2015/06/midwives-are-making-a-comeback/395456/

Readings:

P. Farmer. 1999. Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press.

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

Kim, Jim et al 2000 Dying for Growth: Global Inequality and the Health of the Poor. Monroe, Me.: Common Courage Press.

McKinlay, J.B. and S.M. McKinlay. (1977) The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century. Milbank Memorial Fund Quarterly 55(3): 405-428.

Discussion Questions:

What do you think the role of technology should be in birth? Should birth be treated differently than a disease in terms of the application of medicine and medical technology? Further, how much of this decision should be left to the woman? And what if she doesn’t have the autonomy to make choices or decisions? How should “culture” be treated in these situations?

What do you think about the opposing trends described occurring in the U.S. and developing countries? Do you think that a specific subset of American women rejecting medicalization of birth is relevant to the experiences of most other women globally? Why or why not? Further, can this be understood in a way that doesn’t romanticize the experiences of the poor?

Additionally, why is birth often the focus of these conversations about women’s (reproductive) health? What about menstruation, birth control, and the many other aspects of reproductive health that women have to deal with? (See http://kristof.blogs.nytimes.com/2015/09/01/menstruation-innovation-lessons-from-india/?_r=0 and Holloway as well.) Is this focus similar to the misconception of infectious diseases being so much more prevalent and thus important than chronic diseases in developing countries – that women are dying in childbirth and so it is the most important topic?