Health Professionals' Perception of Maternal Health: an Ethnography in the Sierra De Totonacapan, Veracruz, Mexico
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ORIGINAL RESEARCH Health professionals' perception of maternal health: an ethnography in the Sierra de Totonacapan, Veracruz, Mexico Niels Michael Dörr, MD Abstract (UN, 2013), it is reasonable to question why Maternal health is a complex issue. In maternal health in the region has not improve to an Mexico, the population living in poverty and adequate extent when taking into account MM indigenous peoples are especially affected by (Lozano et al., 2011). It is necessary to examine health disparities, in particular, demonstrated by the way in which the vulnerable population skilled birth attendance. The determinants groups, such as people living in poverty or who mentioned by health professionals, especially are a part of indigenous peoples, are being affected structural barriers, characterize their perception. by this problem. In 2008, 20.9% of all Mexicans However, there are other barriers. The concept of lived in extreme poverty, which was intercultural medicine is understood as the concentrated in rural areas, where 33.5% of its adaptation of medical care to local reality to population is located (Iniguez-Montiel and overcome cultural barriers. This article will Kurosaki, 2018). In 2005, it was estimated conclude with a perspective that focuses on the that 9.8 million indigenous people lived in possibilities and limitations of intercultural Mexico, representing 9.5% of the total medicine for maternal health. Key words: maternal health - maternal mortality - indigenous population (UNDP, 2010) In 2002, extreme people - intercultural medicine - perception poverty in indigenous communities (in which more than 70% of the population is Introduction indigenous) was around 68,5% (Hall and Maternal health is a complex issue. In Patrinos, 2006). When considering the 2010, the global maternal mortality rate (MM) was complexity of the debate about identity and still 240 deaths per 100,000 live births. In Latin ethnicity, statistical surveys must be critically America, according to the UN (UN, 2013), this evaluated (Schmal, no date). Various rate was 72. Despite positive advances in the areas publications have shown that the health status of "skilled birth attendance", "prenatal care" and of the indigenous population is lower than that "use of modern contraceptive methods" (MCM) of other population groups. In terms of maternal health, maternal mortality and Dr. Niels Michael Dörr, MD morbidity rates are significantly higher Universidad Veracruzana, Institute for Research in (Gracey and King, 2009). A 2006 survey by Education the National Institute for Women showed that Justus-Liebig University of Giessen, Institute for the History of Medicine indigenous women used MCMs much less Email: [email protected] frequently than non-indigenous women. In rural areas, only 48.9% of indigenous women Received: December 2019. Accepted: may 2020.. of reproductive age use MCMs, compared Conflict of interest: none. with 61.1% of non-indigenous women (INMujer, 2009). In 2012, the indigenous Social Medicine (www.socialmedicine.info) - 155 - Volume 13, Number 3, September December 2020. population received more support from social populations living in poverty have been neglected programs than the non-indigenous population. in this sense (Ramírez Hita, 2011). In Mexican Notably, more than 50% received support health policy, the concept is generally understood through a nutrition program or the as the adaptation of MA to the local circumstances Oportunidades program. However, the in order to overcome cultural barriers, thus helping improve MA, mainly for the indigenous insurance situation of the indigenous population (Campos Navarro et al., 2017). But in population improved significantly between general, there is no common definition (Salaverry, 2006 and 2012 because, although 64.9% of the 2010). Political understanding and the subsequent indigenous population still did not have health application of IM are criticized in the insurance in 2006, this proportion decreased to anthropological literature. One criticism is that the 22.1% in 2012. By 2012, 61.9% of the concept is applied without significant evidence indigenous population was affiliated with the (Salaverry, 2010). Thus, the question arises as to Seguro Popular de Salud (Leyva-Flores et al., whether the concept should continue to be used, 2013). since there has not yet been any perceptible This publication is based on empirical data improvement with respect to community health from a major German study for the purposes of a (Ramírez Hita, 2011). Therefore, this publication doctoral thesis in medicine (Limits and attempts to clarify the following questions: What possibilities of intercultural medicine for maternal are the possibilities and limitations of the concept health in the Sierra de Totonacapan, Mexico; http: of IM? What benefits can the concept have for //geb.uni-giessen .de / geb / volltexte / 2018/13910 MA? What applications are favorable and how can /), presents a perspective on maternal health in a they be implemented? rural region of the State of Veracruz. It focuses on structural and sociocultural barriers between the "... the doctor is the one who decides" local population and medical attention (MA), and This article is based on extensive the perception of medical personnel (MP) ethnographic field work. For the first focus group, regarding the patients seen. Most of the research a health training was carried out within the on this topic addresses patients' barriers to framework of the Oportunidades program. These equitable health care, for example, socioeconomic trainings were mandatory for pregnant women aspects which contribute to limited access. receiving welfare. The main topics referred to risk (Titaley et al., 2010). In contrast, research factors for pregnancy and childbirth, awareness of on the factors that affect MP is underrepresented to symptoms and preventive measures. The group date (Holmes, 2012). The perception of the MP was made up of 19 pregnant women, a husband, a regarding MA in rural regions is of particular Totonac-speaking interpreter and the male interest in this publication. This article concludes researcher. The objective was to investigate the with a perspective that focuses on the possibilities perception of the participants regarding the and limitations of intercultural medicine (IM). advantages and disadvantages of institutional delivery. At the beginning of the focus group, the Theoretical framework participants were surprised by the format of the The concept of IM has a tradition in event, which was usually oriented towards Mexico in the context of the MA of the indigenous training. Also, it seemed unusual at first that they population (Lerín-Piñón, 2004). The work of the would reveal their opinion regarding MA. anthropologist Gonzalo Aguirre Beltrán is Participants' reluctance was evidenced with the considered of particular relevance. In 1954, statement "So everything is fine at the hospital." Aguirre Beltrán requested to include the concept Particularly impressive was the argumentation of in national health programs (Aguirre Beltrán, one participant: 1994). It is especially used today in the context of “In fact, they make us sign the indigenous culture and traditional medicine consent forms that we want to have the [intrauterine] device and if one cannot, (Menéndez, 2006). Other features are less then the husband does so. I say there is frequently associated with IM. For examples, already negligence, they force you and Social Medicine (www.socialmedicine.info) -156 - Volume 13, Number 3, September December 2020 really we as the owners of our bodies, if working in Coyutla, he continued to live in we do not want to, no one can force us neighboring Entabladero. The results of this to do anything we do not want. Precisely publication are based on 62 semi-structured for this reason many people do not want individual interviews. In addition, 24 structured to go to be treated in hospitals or by the doctor because really the doctor is the interviews were conducted with the MP at the end one who decides, not us. They put it in of the field work, three focus groups each with just like that, even if it doesn't fit. “ pregnant women and in the three medical institutions with MP. Interviews and focus groups Participant observation had previously were conducted in Spanish or the Totonac been carried out at the regional hospital, but no indigenous language. The Totonac interviews were complaints had ever been made in such a way. carried out with the help of an interpreter and later After the focus group, some questions arose that translated and analyzed in detail with her influenced and focused the research discourse: collaboration. Why was the doctor-patient relationship so The authorization to carry out the field patriarchal? Which factors prevent a successful work was obtained through the Intercultural interaction? What effect does this practice have on Veracruzana University (Universidad Veracruzana maternal health? Why have there never been any Intercultural) in Xalapa and by the Veracruz complaints or reports during the participant Health Department (District No. III Poza Rica). observation at the regional hospital? Why do Informants' anonymity was respected without women continue to attend the regional hospital changing the content of the interviews. All daily to give birth? informants were informed about the record of the data collected and they agreed to its use. Methods The field work is based on prolonged Introduction to the field participant observation