Preventable perinatal deaths in indigenous Wixárika communities: an ethnographic study of pregnancy, childbirth and structural violence

Abstract

BackgroundPreventable maternal and infant mortality continues to be significantly higher in Latin American indigenous regions compared to non-indigenous, with inequalities of race, gender and poverty exacerbated by deficiencies in service provision. Standard programmes aimed at improving perinatal health have had a limited impact on mortality rates in these populations, and state and national statistical data and evaluations of services are of little relevance to the environments that most indigenous ethnicities inhabit. This study sought a novel perspective on causes and solutions by considering how structural, cultural and relational factors intersect to make indigenous women and babies more vulnerable to morbidity and mortality.MethodsWe explored how structural inequalities and interpersonal relationships impact decision-making about care seeking during pregnancy and childbirth in Wixarika communities in Northwestern Mexico. Sixty-two women were interviewed while pregnant and followed-up after the birth of their child. Observational data was collected over 18 months, producing more than five hundred pages of field notes.ResultsOf the 62 women interviewed, 33 gave birth at home without skilled attendance, including 5 who delivered completely alone. Five babies died during labour or shortly thereafter, we present here 3 of these events as case studies. We identified that the structure of service provision, in which providers have several contiguous days off, combined with a poor patient-provider dynamic and the sometimes non-consensual imposition of biomedical practices acted as deterrents to institutional delivery. Data also suggested that men have important roles to play supporting their partners during labour and birth.ConclusionsStillbirths and neonatal deaths occurring in a context of unnecessary lone and unassisted deliveries are structurally generated forms of violence: preventable morbidities or mortalities that are the result of systematic inequalities and health system weaknesses. These results counter the common assumption that the choices of indigenous women to avoid institutional delivery are irrational, cultural or due to a lack of education. Rather, our data indicate that institutional arrangements and interpersonal interactions in the health system contribute to preventable deaths. Addressing these issues requires important, but achievable, changes in service provision and resource allocation in addition to long term, culturally-appropriate strategies.Electronic supplementary materialThe online version of this article (10.1186/s12884-018-1870-6) contains supplementary material, which is available to authorized users.

Patient safety in marginalised groups: a narrative scoping review

“…The largest of these, (constituting just over a quarter of the studies (28%)) focused on varying aspects of medication safety [29, 32, 34, 43, 44, 49, 50, 55, 64, 65, 69, 77-79, 85, 86, 88, 92], followed by adverse outcomes (e.g. increased risk of hospital readmission) (22% of all studies) [36, 51-54, 57, 68, 72-75, 81, 83, 84, 93] and near miss in maternal care (10%) [40,48,62,71,76,87,90,94]. Overview of marginalised groups and patient safety issues Figure 2 represents the distribution of patient safety issues and marginalised groups identified across included studies.…”

“Ashamed, Silent and Stuck in a System”—Applying a Structural Violence Lens to Midwives’ Stories on Social Disadvantage in Pregnancy

“…The colonisation of New Zealand in the 1800s resulted in a dominant Pākehā model of governance [ 2 , 12 , 35 ] and knowledge generation [ 29 ]. This has led to a model of health that is focused on individual responsibility, which is at odds with indigenous understandings of holistic health situated within a community [ 31 , 36 ]. At its core, New Zealand’s unique midwifery-led continuity of care model incorporates a holistic philosophy encompassing the wellbeing of the woman and whānau/family.…”

“…These findings align with existing research that impose neoliberal values on health system use and create barriers to health [ 1 , 35 , 46 ]. Scholars have exposed the damage such systems can have on indigenous populations in which these conflicting values systems lead to long-term mortality and trauma increases [ 31 , 47 ]. Gamlin and Hawkes [ 48 ] argue for the need to address the root causes of indigenous women’s unjust disadvantage by starting with the training of health professionals, educational inequalities, structural determinants of poverty and designing locally-tailored initiatives.…”

“…A structural violence lens can lead us away from framing perpetual deficiencies towards making space for new knowledges on the causes of “impoverished material conditions [that are] structured by politically oppressive regimes” [ 29 ]. Gamlin and Holmes [ 31 ] for instance show that a structural violence perspective has the ability to counter the common presumption that the “choices of indigenous women to avoid institutional delivery are irrational, cultural or due to a lack of education” (p. 1) and reveal that these are instead due to institutional and systemic forces that lead to preventable deaths.…”

Violencia y emergencia obstétrica desde la perspectiva de las parteras tradicionales en comunidades rurales

“…Por otro lado, se ha encontrado que en comunidades marginadas las mujeres prefieren dar a luz en su casa en lugar del hospital (Amanuel et al, 2019); un estudio realizado en comunidades indígenas de México reveló que de 62 mujeres entrevistadas, 33 dieron a luz en su casa sin asistencia calificada y 5 dieron a luz completamente solas en sus hogares, y en estos eventos 5 neonatos murieron durante el parto o el período perinatal (Gamlin y Holmes, 2018). Esta preferencia de algunas mujeres en zonas rurales o indígenas por parir en su casa, se puede atribuir a diversos factores, que podrían ser culturales, de accesibilidad a los servicios de salud, desconocimiento o a una resistencia a aceptar los servicios de salud institucional, debido a una experiencia de maltrato o violencia.…”