Structural Violence: An Important Factor of Maternal Mortality Among Indigenous Women in Chiapas, Mexico

  • Mounia El Kotni
Part of the Global Maternal and Child Health book series (GMCH)


In Chiapas, Mexico’s poorest state, indigenous Maya women are twice more likely to die in childbirth than are nonindigenous women. To comply with international development goals and diminish Chiapas’ high maternal mortality rates, indigenous midwives are trained in detecting risk factors in pregnancy and birth, while women are encouraged to give birth in hospitals. This chapter analyzes the consequences of such policies, which might unintentionally exacerbate the structural violence indigenous women face in their lives. In Chiapas, 74.7% of the population lives in poverty and extreme poverty, compared to the national 43% rate. This extreme poverty, the lack of infrastructure, and engrained racism are all factors reproducing violence in the lives of poor women. In the state, the maternal mortality rate of women in reproductive age group has increased between 2010 and 2013 and that of indigenous women has almost doubled (1.7 times) over the same time period. Using an anthropological approach, this chapter examines the institutional and cultural changes in childbirth practices that are occurring in Highlands Chiapas and sheds a light on the structural factors that expose Mayan women to unsafe births, increasing the likelihood that they will suffer mistreatment in childbirth.


Indigenous women Maternal health Skilled birth attendants Birth practices Mexico Chiapas Solitary birth Indigenous pregnancy Maya Pregnancy disorders Maternal death Maternal mortality Reproductive health Structural violence Training Traditional birth attendant Partera Zapatista Prospera 

8.1 Introduction

Located in the southeastern part of Mexico (Figs. 8.1 and 8.2), Chiapas is Mexico’s poorest state: 74.7% of its population lives in poverty and extreme poverty (SEDESOL and CONEVAL 2015). The state often makes the news for its high rates of poverty and maternal deaths, yet the same cultural and economic characteristics that mark it as a marginal place are also presented as central to its identity. In February 2016, during Pope Francis’ visit to the region, which centered the cameras of the world on Chiapas, the constant marginalization that indigenous peoples face on a daily basis dominated the conversation (Mandujano 2016). Similarly, development campaigns led across Chiapas use poor indigenous families as poster children for launch crusades aimed at fighting hunger, educating children, or family planning. These high-profile and newsworthy topics inevitably sideline other issues such as indigenous rights and structural violence, which are then left for local nongovernmental organizations (NGOs) to care for (SIPaz 2014). Despite their marginalization (or sometimes because of it), indigenous peoples claim public spaces and create unique processes in the country.

Map of Mexico (Courtesy of Wikimedia,

Fig. 8.2

Map of Chiapas (Courtesy of SMF)

On January 1, 1994, Chiapas made international news following the uprising of thousands of masked indigenous peoples, reclaiming “work, land, housing, food, health care, education, independence, freedom, democracy, justice and peace” (EZLN 1993). This uprising, known as the Zapatista movement, became the center of international attention and drew crowds to this 4.8 million habitants state. Indigenous people, the majority who are from Mayan descent, comprise 25% of the state’s population and were until then absent from political discourses. In the aftermath of the uprising, much needed infrastructural reforms were implemented in the region, along with government programs to alleviate poverty. While these government efforts have improved some of the population’s living conditions, they have not always been successful, and today Chiapas is the state with the highest rates of people living in poverty and extreme poverty.

Prospera (previously called Oportunidades) is a national program aiming to fight poverty. The program, funded by the World Bank, targets poor mothers, who need to follow a set of rules in order for their family to receive a monthly stipend. The two main branches of the program target education and health, focusing on the “co-responsibility” of mothers in complying with a set of actions. In the case of the maternal branch of the Prospera program, for example, pregnant women have to attend monthly prenatal checkups as well as monthly health workshops at their local health clinic. In addition, they are required to get ultrasounds at the nearest town’s hospital (rural clinics are not equipped with such technology), which is costly in terms of both time and money. Though Prospera’s goal is to improve poor families’ living conditions, the maternal branch of the program aims at improving poor women’s reproductive health through biomedicalization. The program is built on the premise that birthing at home with an indigenous midwife is unsafe, and so if women want to keep their stipend, they have to attend prenatal appointments at their local clinic. Policies such as Prospera thus isolate one factor accounting for maternal mortality—the lack of access to appropriate level of healthcare when needed—and generalize it to all pregnant women, eliminating women’s ability to choose when and where they want to give birth.

In 2000, the United Nations’ Millennium Development Goals (MDG) merged concerns for maternal health and the need for development by relying on health statistics to measure progress in universal access to reproductive health. Through MDG Goal 5.A, developing countries were urged to diminish by three quarters their rates of maternal mortality (together with the complementary MDG Goal 5.B of achieving universal access to reproductive healthcare). In Mexico, the proportion of maternal deaths (per 100,000 live births) has moved from 77 in 2002 to 54.7 in 2013 (OMM 2013), after which it increased again to 68.1 in 2014. A closer look at these numbers reveals that rural indigenous women are the ones who still die in childbirth.1 In Chiapas, the maternal mortality rate (MMR) of women in reproductive age group (between 15 and 49 years old) has actually increased between 2010 and 2013 and that of indigenous women has almost doubled (1.7 times) over the time period (ibid). What factors put indigenous women at greater risk of dying in childbirth?

To answer such a question, this chapter relies on an anthropological approach to uncover the realities behind the statistics of maternal deaths. In this chapter, I argue that an anthropological approach to maternal death needs to take into account the structural factors which lead too many indigenous women to die during pregnancy and childbirth. Anthropology focuses on individual stories while replacing them in the broader context of international policies, as well as national and local settings of violence. This chapter concludes with some examples of local activists and midwives organizing to change these statistics.

8.2 An Anthropological Approach to Maternal Deaths

The research presented in this chapter stems from 13 months of ethnographic fieldwork in Chiapas, Mexico, between 2013 and 2015. All the participants in this study have given their informed consent, and the study itself has been approved by the Institutional Review Board at the University at Albany. During my stays in Chiapas, I have been in contact with indigenous and nonindigenous midwives, medical staff in public hospitals, workers of the Ministry of Health, mothers, activists, and researchers. The ethnographic research methods I used included qualitative in-depth interviews, observation (what people do), participant observation (participating in daily activities), and long-term immersion into the field (Bernard 2006). Combined, these qualitative research methods bring to the surface underlying social mechanisms and dynamics, which could not be revealed by one of these methods alone.

What is central to the discipline of anthropology is the trust building with our participants, called “rapport” in anthropological jargon. This trust building happens through seemingly non-research activities: making tortillas, attending a religious ceremony, learning how to greet strangers, chatting. As anthropologists have shown, these actions help members of the community judge the research and integrate her/him in their social network, which then leads to agreeing to share their personal story (Bernard 2006; Eber 1995; Little 2004). Medical anthropologists have highlighted the difficulty of conducting participant observation in the context of public clinics. How much participation is allowed, and what type of knowledge is accessible, varies depending on hospital and university regulations but also on very down-to-earth criteria such as the friendliness of the staff (Andaya 2014; Gálvez 2011; Howes-Mischel 2012). The long-term involvement on their field sites allows anthropologists to gain a unique access to people’s personal stories, sometimes across generations and borders, like in the case of Rebecca Howes-Mischel who worked on indigenous women’s reproductive care in Oaxaca, Mexico, and in the United States (2012).

The combination of various research methods, as well as the time spent alongside our informants, lies at the core of anthropological research and allows medical anthropologists to shed a light on the local consequences of global health policies.

8.3 International Health Policies

At global, national, and regional levels, the Every Newborn Action Plan is supporting developments in health programs, for pregnant women, mothers, and their newborns. (…) Now there is good evidence that these investments in self-help groups are also paying off: as women encourage and support one another to adopt both pre and postnatal care routines. And what I’m excited about about [sic] self-help groups, is [that] we’re learning how to really measure the results they are getting, and I think we’re only going to get better at that as a world, and that’s going to help us with the supply and demand issues that we have to get women really using the services provided. (Melinda Gates, Global Maternal Newborn Health Conference (GMNHC), Mexico City, October 19, 2015 (GMNHC 2015))

Melinda Gates’ discourse, held at an international conference on maternal and child health in Mexico City, illustrates the many paradoxes of Mexico: a country where people die from poverty-related illnesses yet one that is eager to become Latin America’s next leader. In order to achieve this goal, Mexico measures its progress through statistics and maternal and child health indicators in particular. As anthropologists working in the field of birth have pointed out, at the global level, these indicators serve as a scale to measure nations’ economic development and their progress toward achieving modernity (Andaya 2014; Howes-Mischel 2012). Countries like Mexico invest in hospital-based birth so as to become modern and credible in the eyes of international institutions. In the United States, 99% of babies are delivered in hospitals (Gálvez 2011, p. 87). Mexico follows in these footsteps: in 1990, 76.7% of births occurred in health institutions; in 2013, it was 96.1%. The changes are even more significant in Chiapas, one of the states where a large number of women still give birth at home; in the last 25 years, numbers increased from 22.4% up to 72.9% (OMM 2013, p.28).

Poor women’s reproductive choices have been on the international agenda since the 1970s; however, it is the International Conference on Population and Development meeting in Cairo, Egypt, in 1994 that framed for the first time women’s reproductive health as a human right. The following year, the Fourth World Conference on Women in Beijing, China, implemented the Gender and Development approach, which tied economic empowerment to women’s reproductive choices. The Gender and Development approach promotes women’s empowerment through their participation in the public sphere, which is intimately connected to their reproductive behaviors. Policies created under the Gender and Development approach overlook the fact that choices are “inseparable from the economic and physical hardships [women] endure under global conditions” (Ginsburg and Rapp 1995, p. 14). The emphasis on individual choice of family planning does not necessarily lead to improving women’s care or diminishing maternal mortality rates, which are never “entirely matters of private, individual, and moral concerns” (Pinto 2008, p. 221). For example, even in a context of a socialist state providing free childcare like Cuba, women struggled to balance work and family life (Andaya 2014).

International policies aiming at improving mother and child health have focused on the training of “traditional birth attendants” (TBAs) since the 1970s. From Malawi to Mexico, the stereotypical TBA targeted by these policies is an older woman who has not received formal schooling and relies on her empirical knowledge and practical experiences to help women deliver their children at home (Berer and Sundari Ravindran 2000). Launched in 1987, the Safe Motherhood Initiative (joined by Mexico in 1993) relies on a rhetoric of modernity to encourage women to give birth in hospitals and to push the TBAs to transfer their patients from home to clinics (Berry 2010). Following the Safe Motherhood Initiative, and the funding which resulted from the program, maternal mortality and maternal and child health became major concerns in every developing country (Berer and Sundari Ravindran 2000).

Anthropologists have questioned the shift in the World Health Organization’s (WHO) policies regarding traditional midwives, who moved from allies in diminishing international maternal mortality rates in the 1970s and 1980s to antagonists in the 1990s after the rates did not decrease (Berry 2010; Pigg 1997). In parallel to the dismissal of TBA’s knowledge, international guidelines pushed for the training of skilled birth attendants (SBAs). In contrast to TBAs, SBAs are personnel who have undergone formal training and are able to navigate the hospital environment. Still today, SBAs are seen as the key element to improving poor mothers’ health (United Nations 2014), as illustrated in another part of Melinda Gates’ speech:

Quality care at facilities is one of the absolute keys to saving mothers and newborns. So we need to continue to insure that we are satisfied and that those Skilled Birth Attendants are staffed at all clinics for women. That the clinics themselves are well-supplied and well-trained, so that we can make childbirth even safer. (GMNH 2015)

Gates’ quote illustrates the contemporary face of maternal mortality reduction policies. The presence of SBAs in health centers and clinics is proportionate to the absence of TBAs, who deliver babies in homes. The former are integrated in the health system and provide quality care, while the latter work outside of the system and are implicitly associated with maternal deaths. In Mexico, to comply with international development goals and diminish maternal mortality rates, indigenous midwives are trained in detecting risk factors in pregnancy and birth, while women are encouraged to give birth in hospitals. In 2000, the United Nations’ Millennium Development Goals (MDG) merged concerns for maternal health and the need for development by relying on health statistics to measure progress in universal access to reproductive health. Through MDG Goal 5.A, developing countries were urged to diminish by three quarters their rates of maternal mortality. In Chiapas, the proportion of maternal deaths (per 100,000 live births) decreased from 77 in 2002 to 54.7 in 2013 (OMM 2013), before increasing again to 68.1 in 2014.2

8.4 Life and Death in the Highlands

8.4.1 Structural Violence as Risk Factor

As stated in the Introduction of this chapter, in Chiapas, 74.7% of the population lives in poverty and extreme poverty, compared to the national 43% rate3 (Enciso 2014). Highlands Chiapas (Fig. 8.3) concentrate the poorest municipalities of the state. In the Highlands, 65% of the municipios (municipalities) are classified as having the highest rate of marginalization (CONAPO (Consejo Nacional de Población). 2010, p. 88). Ethnicity and poverty often conflate, and the indigenous population of the state is also the poorest (Nash 2001; O’Donnell 2010).

Mayan women and their families experience tremendous economic hardship, including extreme rates of malnutrition, lack of running water and electricity—conditions which produce poverty—related illness like TB, intestinal problems due to unclean water sources, and high rates of infant and maternal mortality. (O’Donnell 2010, p. 18)

Fig. 8.3

Map of Highlands Chiapas (Courtesy of GIRE)

The concept of “poverty-related illnesses” demonstrates the violence of poverty: men and women live in infected environments and die of curable diseases, and indigenous women die in childbirth. Anthropologists have considered poverty as a form of violence exerted by a state on its citizen and more generally by the global social order toward poor people (Farmer 2005; Gupta 2012). Poverty adds on to the many forms of violence indigenous women face on a daily basis; “There are many forms of violence—domestic violence, sexual violence, and poverty which is violence to women’s minds, hearts, and bodies, as they worry about the next day and how to get food” (O’Donnell 2010, p. 119). Out of the 18 municipalities of the Highlands jurisdiction, San Cristóbal, the cultural capital of the state, is the only one that is not considered as having “high” or “very high” marginalization. In the last national census, Chiapas had the highest fertility rate (3.07), while the national average was 2.39.4 In this state, women have experienced the loss of 9.4% of their children—almost one out of ten (INEGI 2010).

In Chiapas, indigenous people have been living in a state of low-intensity warfare since the Zapatista uprising of 1994 and the government’s violent response, which concretely and directly impacts women and their health. In the Highlands, the deployment of paramilitaries has fueled gender-based violence; indigenous women report being harassed and sexually violated by the military (Antillón Najlis 2013). Violence is the product of a multiplicity of forces that intertwine and reinforce one another and can be lethal for poor women.

We also think of the women in Chiapas who have died for having fought for a new life, about those women who have died because of a lack of health services, who have died from domestic violence. (O’Donnell 2010, p. 210)

The combination of warfare and lack of healthcare illustrates the “absent present state,” a concept developed by anthropologist Daniel Goldstein in his work in Bolivia (Goldstein 2012): a state very much present through its armed forces but desperately absent when infrastructure is needed. Similar to Bolivia, the absence presence of the Mexican state reinforces structural violence5 in the lives of the poor and marginalized. In Chiapas, the state was very much present in the years following the Zapatista uprising; over 55 million pesos (about US$ 7 million at the time) were transferred from the federal to the state level between 1995 and 1997 (Freyermuth Enciso 2003, p. 349). Despite an improvement in the infrastructures and the construction of rural clinics, maternal mortality rates (although they have decreased) are still among the highest of the country (Fig. 8.4).
Fig. 8.4

Rural village in Chiapas. Published with kind permission of © Mounia El Kotni 2017. All Rights Reserved

Structural violence can be defined as an abstract violence that cannot be traced directly to health institutions or individuals (Galtung 1969); it is the “violence of injustice, (…) caused by social structures and processes that marginalize people and sustain social inequalities” (Rylko-Bauer et al. 2009, p.7).

When analyzing risk factors in health, medical anthropologists have included the structural conditions under which people live, such as poverty and marginalization (Farmer 2005; Rylko-Bauer et al. 2009). In Mexico as in other settings, the challenges women face in childbirth are deeply rooted in the social constructions surrounding reproduction (Andaya 2014; Jordan 1993; Murray de López 2016). When combined to structural barriers, such as the lack of access to health clinics in rural areas, policies aiming to reduce maternal mortality rates might send out the message that the bodies of poor women need to be controlled, inscribing women’s access to healthcare into socioeconomic hierarchies. One-size-fits-all solutions promoted by international organizations homogenize the historical, political, and social factors that underlie women’s lives. Stratified reproduction becomes a useful tool to analyze structural and global factors constraining poor women’s reproductive choices.

8.4.2 Maternal Mortality and Stratified Reproduction in Chiapas

In Mexico, historical inequalities put indigenous women more at risk of dying in childbirth (Chopel 2014; Freyermuth Enciso and Argüello Avendaño 2010). In Chiapas, indigenous women represent less than one-third of the female population (Gobierno del Estado de Chiapas 2014) but almost one-half of the overall maternal deaths (OMM 2013). Women, depending on their socioeconomic status and ethnicity, do not have the same power to make decisions over their reproductive health—what Shellee Colen coined stratified reproduction (Colen 1995; Ginsburg and Rapp 1995).

In her work with West Indian care providers in New York City, Colen highlights how immigrant women give up their own reproductive life, often leaving children in the hands of family networks in their home countries, to nurture the children of wealthier women in the United States (1995). Stratified reproduction is rooted in social inequalities and often mirrors social stratification.

The desirability of one’s reproduction is tied to idea(ls) of citizenship, making reproductive futures easier for some groups and more difficult for others, and is intimately tied to hierarchies of nationality, class, and ethnicity. For Maya women in Chiapas, maternal health policies can contribute to stratified reproduction, by controlling where and how they should give birth—while wealthier women in the same region can have access to private clinics or professional midwives (El Kotni 2016a; Murray de López 2016).

Table 8.1 illustrates the maternal mortality rates of Chiapas, compared to national maternal mortality rates and the 2015 Millennium Development Goal. Although both national and state rates decreased between 2002 and 2013, the decrease is not constant, and in Chiapas there are several examples of an increase of maternal deaths from 1 year to another. As stated in the introduction, at the national level, the rate of maternal deaths (per 100,000 live births) has moved from 77 in 2002 to 54.7 in 2013 (OMM 2013), before increasing again to 68.1 in 2014. In Chiapas, the maternal mortality rate of women in reproductive age (between 15 and 49 years old) has actually increased between 2010 and 2013 and that of indigenous women has almost doubled (1.7 times) over the time period (ibid). Under the Millennium Development Goals, Mexico’s strategy has been to train TBAs, namely, indigenous midwives, to detect risks in pregnancy and transfer to hospitals. In the next section, I discuss this strategy.
Table 8.1

Maternal mortality rates in Chiapas and Mexico (2002–2013) (Source: OMM 2013)

8.4.3 Government Campaigns Against Maternal Mortality6

At each consult with a pregnant woman, Doña Gabriela starts by asking: “Does your head hurt? Do you hear buzzing in your ears? Do you feel nauseous? Have you vomited? Do you see little lights?” After more than 15 years of monthly trainings at a local clinic, these questions have become part of Doña a Gabriela’ s routine. Doña a Gabriela knows that if the woman answers yes to one of these questions, called señales de alarma (danger signs) (Figs. 8.5 and 8.6), it means that she (a midwife) might not be allowed to attend the woman’s birth:

If the woman has all of these [signs], then we won’t be overseeing the birth, it is better if she goes with the doctor. This way, we come out clean. This is what we learn. (…) [When we get to the hospital] we just hand the woman over and that’s it. They don’t allow us in. We hand her over in the emergency room, that’s it. Before, they allowed us in, but now they don’t anymore.

Fig. 8.5

Alarm signals in pregnancy, a poster in Spanish. Published with kind permission of © Mounia El Kotni 2017. All Rights Reserved

Fig. 8.6

Ritual prayer. Drawing by Alice Bafoin

In some rural areas of Highlands Chiapas, traditional indigenous midwives like Doña Gabriela (parteras in Spanish7) attend up to 70% of births (Gómez Mena 2012). Following international guidelines from the WHO, the steps to diminish maternal mortality rates have focused on training these birth attendants. Mexican public health policies encourage practitioners in health centers and clinics to train the parteras in the detection of danger signs, while on their end, parteras are urged to transfer their patients to hospitals. The trainings for midwives focus on the opportune detection of alarm signals during pregnancy, birth, and postpartum. The doctors and nurses who train them insist that the parteras learn these signals in order to recognize them and immediately transfer women to the nearest hospital. While opportune transfers have the potential to save the lives of the mother and child, government trainings do not discuss alternatives to transfer, in a context where the distance to the nearest hospital can often be of 6 or 7 h, with patients having to pay for the cost of transportation. State policies aiming to train indigenous midwives gradually reshape their role in the healthcare system; indigenous parteras shift from being independent healthcare providers to becoming health auxiliaries (El Kotni 2016a).

Since the WHO’s launch of the Safe Motherhood Initiative in 1987, international efforts have focused on training TBAs in hygiene (boiling instruments, washing hands) and encouraging them to refer women to hospitals. In this framework, pregnancy and childbirth are perceived as risky processes, with every pregnant woman being potentially at risk of having a complication. Anthropologists working in different cultural settings have analyzed how the medical discourse transforms a natural event into a risky one (Fordyce and Maraesa 2012). The Mexican state’s particular construction of birth as a risky process, combined with monetary incentives to give birth in hospitals through conditional cash-transfer programs targeting poor women (Prospera), constrains women’s reproductive choices and disrupts Mayan women’s birth practices. Birth is no longer a natural event where the woman is supported by her family but becomes a risky practice performed by a technocrat, the obstetrician (Jordan 1993).

Given the cultural importance of birthing at home in Maya-speaking communities (discussed in the next section), surrounded by one’s family and in-laws, and with very little intervention, the shift from home to hospital is not only a change of physical place but also of space, social environment, and language. In indigenous women’s and midwives’ accounts, the hospital is often described as an unfamiliar place with foreign codes, a dangerous place in which women are reluctant to give birth (Berry 2006; El Kotni 2016a).

During their encounter with government workers and medical staff, indigenous women are exposed to a discourse built on the premise that birthing at home with a traditional midwife is unsafe and that hospitals are the best place to give birth for all women—and poor, indigenous women in particular (Smith-Oka 2009). The paradox of insisting that parteras transfer women to hospitals is that even when they do so in cases of labor complications, they are still blamed for the situation. Parteras and mothers are scolded for attempting what is considered a risky birth—that is, trying to birth outside of the hospital. Because the national policies urge midwives to send every woman to the hospital, public hospitals are saturated, and an efficient birth is a quick birth. The search for efficiency leads to routine episiotomies and skyrocketing cesarean section rates (Mexico has the second highest cesarean section rate among OECD countries8). Since there is a high chance women will be badly treated in hospitals, sometimes family members refuse to send women to the hospital, even if parteras are able to identify alarm signals. These structural factors are part of the explanation behind the rates of maternal deaths in the region.

8.4.4 Homebirth as a Cultural Practice

The gift that the partera has, it has been given to her by God. It is not something easy, to care for women in childbirth; it is not for everyone. Because the most important thing is the life of the baby and of the mother. The parteras, they work day and night, at any time; there is always work for parteras, and it is now that we have to pass on this knowledge, for the benefit of the mother and her family (…) We must not lose these medicinal traditions, because they are transmitted from generation to generation. (Maya partera, during a meeting of the Organization of Indigenous Doctors or Chiapas in 2014)

Pioneering medical anthropologist and ethnographer Brigitte Jordan (deceased 2016) developed a biosocial framework to analyze childbirth, by highlighting that while birth is a physiologically universal event, it is also deeply culturally constructed (1993). In Mesoamerica, traditional midwives are key actors during pregnancy and childbirth. Their hands can tell when a child is due and replace it correctly if they detect an abnormal positioning (breech). Parteras also rely on their wide knowledge of plants and their properties, transmitted through generations, to care for women and their families. During their pregnancy, Maya women accumulate heat, an energy needed to create a new life. Childbirth, the culmination of pregnancy, is a very “hot” stage because of the accumulation of blood of the mother (from the retained menstrual blood) (Freyermuth Enciso 2003; Groark 1997; Guiteras Holmes 1961, p. 105). In the Highlands, birth is a family event: the woman labors at home, fully dressed, with the help of her husband (who sustains her while she is squatting, as in Fig. 8.7); the partera massages her (sobada), performs prayers, and catches the baby, while family and in-laws are in charge of warming the room and heating water, among others (Berry 2010; Freyermuth Enciso 2003; Jordan 1993). As women lose blood during labor, they lose heat and must be careful not to fall into a colder state. This is the reason why sources of heat such as the kitchen fire, the temazcal, and the various teas that a woman is given to drink are essential elements during childbirth. Some anthropologists analyze the masculine presence of the husband or father-in-law during childbirth as an element that reflects patriarchal control over women’s reproductive decisions (Freyermuth Enciso 2003). However, some indigenous midwives interpret the future father’s presence as an important emotional support facilitating the birthing process. In the neighboring state of Yucatán, women also express that the father’s presence makes his bonding with the child easier (Miranda 2015). This situation is in stark contrast with what happens to women in the hospital, where the loneliness they experience is perceived by their families and parteras as an element of complication during childbirth—which is common across the Mayan region (Berry 2008).
Fig. 8.7

Homebirth in the Highlands. Drawing by Alice Bafoin

During birth, the mother alternates positions, the most common being a squat with the support of the husband, seated on a chair (Fig. 8.7). Among Catholics, the midwife also provides support through prayers, candles, and chants (Fig. 8.6). During the immediate postpartum,9 the midwife works in team with the rest of the family, making sure that both the mother and the baby are cared for. They do not cut the umbilical cord until the placenta (meaning “the mother of the baby” in Maya-Tseltal) is delivered. Practices regarding the disposal of placenta vary throughout the region, but most of the women and parteras bury it (Cadenas Gordillo 2002; OMIECH 2011; Freyermuth Enciso 2003).

The various therapeutic elements used during birth—heat, plants, and prayers—as well as the presence of the family contrast with the treatment women receive in public hospitals. There, women are confronted with a staff that often does not speak an indigenous language and are left to labor alone in a cold environment. These are some of the reasons why many women and their families refuse to go to hospitals, despite the government pressures to do so.

8.4.5 Difficulties of Accessing Healthcare Structure

The midwives are the first contact. It is important. Women, they keep having trust in the midwives. While there is a good control, there are no problems; the midwife knows it. The problem is if she does not identify the alarm symptoms, when there are risks. (Male doctor in urban health center)

Located in Highlands Chiapas, a couple of hours in public transportation from San Cristóbal, the town of Oxchuc (on Fig. 8.3) benefits from one public health center and one clinic. Twice a month, the only doctor and director of the health center meets with the midwives: the first meeting consists of a training course, and the second one is for the midwives to report their activities. “The themes of the trainings change, but always with a focus on risk.” The doctor adds that in this center, out of 100 births, 60 are considered high risk, either because the woman has had more than four children or because she is a teenager. While he takes pride in the fact that thanks to this program maternal deaths have diminished, he also notices a correlative effect: “the care by midwives has decreased.”

In most public health institutions, in order to lower maternal mortality rates, the staff trains indigenous midwives in the detection of alarm signals in pregnancy and childbirth. If the midwives were to encounter any of the signals, they should report the woman to their local clinic in the case of a pregnancy and transfer to the nearest hospital in the case of a birth (Fig. 8.8). The midwives affiliated with this health center comply with transferring their patients from home to the hospital if they detect an alarm symptom, but, according to the doctor, those who do not come to the trainings “attend risky births].” Moving beyond the discourse of individual blame, why do some midwives do not transfer women to the hospital? The paradox of the trainings in rural towns like those around Oxchuc is that even if/when the midwife detects a complication, she cannot transfer to the health center outside of opening hours (8 am to 4 pm, Monday to Friday); and neither the health center nor the clinic in the main town is equipped to perform a cesarean section. The woman needs to be transferred while in labor to one of the two closest hospitals (San Cristóbal de las Casas or Ocosingo), each 90 min away from this municipal center. Like in Guatemala, for this reason physicians encourage women to go to the hospital before a complication emerges (Berry 2006). However, as described in the next section, these recommendations also contribute to overcrowding in public hospitals. Women such as those that traditional midwives attend in Oxchuc (Fig. 8.9) do not have private health insurance and cannot afford to pay for a private clinic at any stage of their journey. They face economic and social barriers that impede their access to health facilities and ultimately impact their health conditions.
Fig. 8.8

Waiting outside an urban clinic. Published with kind permission of © Mounia El Kotni 2017. All Rights Reserved

Fig. 8.9

Prenatal consult at home. Published with kind permission of © Mounia El Kotni 2017. All Rights Reserved

The strategy of sending virtually all women to give birth in hospitals in order to lower the prevalence of maternal deaths has led to the saturation of public hospitals (like in Guatemala, (Cominsky 2012)). More women also go to the hospital because of government programs such as Prospera, which aims to send them to give birth with skilled birth attendants but without the necessary infrastructures. As mentioned earlier, the need to attend to as many patients as possible contributes to the rising rates of cesarean sections in Mexico (70% in private hospitals and 40% in public hospitals at the national level (Sánchez 2010)).

This was a strategy that the government initiated, not just here in Mexico, but in many countries, that was suggested to diminish infant mortality; hospitals are saturated and a C-section is a good way of programing who comes in, when they do, and when they come out. [We have] a failed health system that does not know how to care for pregnant women—C-sections are a clear example of that—and it is not possible that we keep having a C-section rate three times higher than what is recommended by the World Health Organization. (Redacción AZ Noticias 2015)

Despite infrastructural changes in the past decades, including the construction of roads and rural clinics (Fig. 8.10), indigenous women still live at the margins of Mexican society, targeted by development programs (such as Prospera) that focus on their reproductive behaviors.
Fig. 8.10

A rural clinic in Chiapas. Published with kind permission of © Mounia El Kotni 2017. All Rights Reserved

8.5 Obstetric Violence Is Structural Violence

Maternal mortality might be one of the most serious expressions of a series of omissions and violations of the economic, social, and cultural rights of the woman and her whole community (Arana 2002).

Framing maternal health as a matter of human rights underlines the injustice of maternal deaths, which can then be analyzed as violations of women’s rights. It also highlights how blaming indigenous midwives is a violation of their rights as indigenous peoples. This blame happens in everyday discourses and is implicit during government trainings for parteras. In San Cristóbal de Las Casas, the Organization of Indigenous Doctors of the State of Chiapas (OMIECH) addresses the injustice of indigenous maternal deaths in a comparative perspective: why are indigenous midwives systematically blamed for maternal and child mortality when hospitals are not held accountable for routinely violating women’s rights?

They never admit that babies die, that mothers die over there [in the hospital]. They put the blame on the women, on the parteras, because they are indigenous… (…) [They say] that the midwife is worth nothing, that it is the pregnant woman’s fault, that it’s because of this, because of that…. (OMIECH founder, cited in El Kotni and Icó Bautista 2014)

For OMIECH, there is an uneven reaction to maternal mortality depending on where it occurs. Indigenous midwives are systematically blamed, while doctors are hardly ever held to account because of the social prestige their profession carries. On the other end, poverty and illiteracy make it difficult for indigenous women to navigate the medical system. In Chiapas, only 28.8% of indigenous women from 15 to 19 attend school, compared with 48.7% of nonindigenous women (INEGI 2009). Similar to other states of Mexico, indigenous women suffer:

different kinds of institutional violence and ethnic and gender discrimination, for example when they are discriminated against in health services because of their monolingualism, when doctors fail to explain ailments or treatments to them, or when they try to make a complaint and the state authorities scold and insult them. (Sieder and Sierra 2010, p. 25)

In a national context of widespread gender-based violence, where women struggle to gain control over their own body (Arteaga Botello and Valdes Figueroa 2010), the hospital becomes a place where violence is reproduced, as women’s intimate reproductive experiences are controlled by male (or masculinized) professionals. The treatment women receive in hospitals pushes them away. Such was the case for Carlita, a 20-year-old mother of indigenous descent living in San Cristóbal.

When labor started I went to the hospital, but they wouldn’t pay attention to me. Finally, a doctora checked me [performed a cervical exam]. She told me to go back home because I still had time. The doctora was nice, but I did not like how she touched me. So when I left [the hospital], I told my mother ‘I don’t want to give birth in this place, it’s better to call my grandmother so that she can come and care for me at home.’ (Interview, April 2015)10

When indigenous women do not comply with the government programs (of giving birth at a clinic) or expectations of modernity (of having less children), they expose themselves to scolding, coercion, and mistreatment from the health personnel. The violation of women’s reproductive rights during childbirth takes the form of verbal insults (Castro and Erviti 2003), routine invasive procedures (including cervical checks (Smith-Oka 2013) and uterine revision (Zacher Dixon 2015)), and forced sterilization (Castro 2004), among others. The physical violence women experience in the maternity ward is one of the reasons some women refuse to go to the hospital (Berry 2008; Smith-Oka 2013; Zacher Dixon 2015). Women’s fears stem, to some degree, from such stories of violence which are in part linked to the poor working conditions of public hospitals in Mexico and which are reinforced by the medical, gender and ethnic stratification occurring during the medical encounter.

Researchers and NGOs have been documenting obstetric violence in Mexico for more than a decade (Castro and Erviti 2003; Freyermuth Enciso 2004; Kirsch and Arana 1999). In 2013, the photograph of an indigenous Mazatec woman giving birth on the lawn of a Oaxacan hospital after being denied medical care was widely shared on the internet (Gomez Licon 2013). The picture created outrage throughout the world, with Mexican organizations urging the government to act on the topic of obstetric violence. Since then, organizations from the civil society such as the Information Group on Reproductive Choice (GIRE) have encouraged women and their families to present demands to the National Commission of Human Rights (CNDH) and lobbied for legislation on the matter. Currently, three states criminalize obstetric violence—Chiapas, Guerrero, and Veracruz—and similar legislation is underway in two others (Jalisco & Zacatecas) (GIRE 2015a).

In line with international organizations, GIRE places obstetric violence on the human rights terrain, to achieve the WHO standard of “every woman’s right to the highest attainable standard of health, which includes the right to dignified, respectful health care.” In particular, women of low socioeconomic status and minorities are more likely to suffer obstetric violence. In their 2015 report, GIRE analyzes how criminalizing obstetric violence is not the solution to its ending; rather the state should recognize such violence as institutional violence and act to provide women with quality care (GIRE 2015b).

In the hospital, actions of violence are not always “the product of the acts of rogue individual practitioners, but rather of a systemic failure that reinforces outdated practices” (Zacher Dixon 2015, p. 449). The medical professionals I have met have been generally very skeptical about such laws, which are impossible to implement, “the Obstetric Violence law has a very noble purpose and very good concepts; the problem is that [politicians] they make such a law and [as a doctor] you think: ‘and how am I going to implement this if I don’t have any means?”, (female obstetrician working in urban hospital). Another limitation of the law is the lack of legal recourse to denounce obstetric violence and the little trust Mexicans, and indigenous people in particular, have in their judicial institutions (Sieder and Sierra 2010).

8.6 Contesting Violence: Midwives Organizing

Since the Zapatista uprising in Chiapas, human rights have provided a powerful framework for NGOs and civil society to call attention to the structural violence in indigenous peoples’ lives. Organizations working in the field of indigenous health rely on human rights to reframe maternal deaths not as the consequence of partera care but as the outcome of a series of state neglect. A human rights approach to maternal mortality allows framing maternal deaths as a violation of women’s rights. It also points out to the complex entanglement between rights, culture, and blame, reinforced by government programs focusing solely on midwifery training to diminish maternal mortality rates.

The Organization of Indigenous Doctors of the State of Chiapas frames health and reproductive knowledge as a right—a right that can save lives. Although OMIECH started to form in the late 1970s, it was officially founded in 1985. The organization’s headquarters are located in San Cristóbal de Las Casas, but communities from any region of Chiapas can decide to become members. The goal of the organization is to valorize indigenous medical knowledge by training health promoters and midwives in the Highlands of Chiapas through community workshops (Fig. 8.11). To date, there are 13 communities within 11 municipalities participating in the project. In the face of the stigmatization of indigenous midwives and of government incentives for women to give birth in hospitals, OMIECH members have revived indigenous plant knowledge and natural care for women, reinforcing in turn the cohesion of the community which is then better prepared to face an emergency. The organization runs the Museum of Mayan Medicine in San Cristóbal and has promoted its work through partnership with organizations in France and Germany. The 50 midwives who constitute the membership of the organization also meet annually to share their knowledge about reproductive health and their concerns about changes in their communities.
Fig. 8.11

OMIECH community workshop with women and midwives. Published with kind permission of © Mounia El Kotni 2017. All Rights Reserved

In a 2005 documentary on homebirth in Mayan communities, the organization highlights the importance of the traditional knowledge of midwives, who speak the same language as the women they care for and are available at any time of the day or the night to attend a birth in the mother’s home (Icó Bautista 2005). As described earlier in this chapter, indigenous midwives’ role is not limited to childbirth; they also carry a variety of knowledge related to healthcare. OMIECH claims that medicine is not only Western and that indigenous medicine should not be perceived only as a replacement when the former is lacking. The simultaneous use of the two medical systems is not uncommon in Chiapas (Ayora Diaz 2000). What OMIECH argues is for Mayan men and women to be able to turn to both systems of medicine to exercise their right to health, without fearing socioeconomic punishment.


In this chapter, I discussed how in Southern Mexico, when it comes to the politics of birth, the sociocultural determinants to healthcare access put some women at risk more than others. In Highlands Chiapas, poor mothers, often of Maya descent, are the target of government programs aiming to diminish maternal mortality by encouraging them to give birth in medical structures rather than in their homes with an indigenous midwife. The desire to attract indigenous people into the hospital for childbirth results from Mexico’s global commitments to improving their health conditions but has so far focused on training midwives in detecting alarm signals, transferring their patients, and pressuring women to give birth in hospitals. These two policies have led to overcrowding of public hospitals, which has increased both cesarean section rates and the violation of women’s human rights in childbirth. By not focusing on the structural roots of maternal deaths, such as poverty, racism, and marginalization, the policies will continue failing indigenous women and their families.


  1. 1.

    Those numbers reflect deaths that have been reported and registered as maternal deaths. Research has indicated a severe underreporting of such deaths, partly due to the pressure to comply with MDGs (Freyermuth Enciso and Cárdenas Elizalde <CitationRef CitationID="CR29" >2009</Citation Ref>; Freyermuth, this volume).

  2. 2.

    The national goal for the country was 22.2, which Mexico did not reach (the 2015 national MMR was 38.2) (Objetivos de Desarrollo del Milenio #5 <CitationRef CitationID="CR55" >n.d</Citation Ref>.).

  3. 3.

    Disparities are even stronger for extreme poverty: 38 percent for Chiapas, 7.9 percent at the national level.

  4. 4.

    The fertility rate is much higher in rural areas: out of the forty-four parteras I interviewed, half had carried over four pregnancies.

  5. 5.

    Galtung (<CitationRef CitationID="CR30" >1969</Citation Ref>) identifies structural violence as violence that cannot be traced directly to an actor or institution. Structural violence is intimately linked to social injustice, which was at the heart of the Zapatista demands.

  6. 6.

    Partly reproduced from a post on Anthropology-News (El Kotni <CitationRef CitationID="CR21" >2016b</Citation Ref>).

  7. 7.

    Partera is the generic word for midwife in Spanish. It has been used to refer to indigenous midwives and professional midwives alike.

  8. 8.
  9. 9.

    The postpartum period is divided into the first or acute phase (the first 6–12 h), the second or subacute phase (2–6 weeks), and the third or delayed postpartum period (up to 6 months) (Romano et al. <CitationRef CitationID="CR62" >2010</Citation Ref>).

  10. 10.

    Carlita’s son was born in her home with the help of her grandmother, a recognized midwife in her community.


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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Anthropology DepartmentUniversity at Albany AS 237AlbanyUSA

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