Durham E-Theses The social context of family planning policy in highland Chiapas, Mexico. Thompson, Mary Summers How to cite: Thompson, Mary Summers (1999) The social context of family planning policy in highland Chiapas, Mexico., Durham theses, Durham University. Available at Durham E-Theses Online: http://etheses.dur.ac.uk/4587/ Use policy The full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-prot purposes provided that: • a full bibliographic reference is made to the original source • a link is made to the metadata record in Durham E-Theses • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders. Please consult the full Durham E-Theses policy for further details. Academic Support Oce, Durham University, University Oce, Old Elvet, Durham DH1 3HP e-mail: [email protected] Tel: +44 0191 334 6107 http://etheses.dur.ac.uk 2 The Social Context of Family Planning Policy in Highland Chiapas, Mexico. Mary Summers Thompson Department of Anthropology University of Durham Submitted in partial fulfillment for the requirements of the degree of PhD January 1999 The copyright of this thesis rests with the author. No quotation from it should be published without the written consent of the author an information derived from it should 36 acknowledged. The copyright of this thesis rests with the author. No quotation from it should be published without their prior written consent and information derived from it should be acknowledged. ABSTRACT The Social Context of Family Planning Policy in Highland Chiapas, Mexico Mary S. Thompson PhD 1999 This thesis focuses on the concept of informed choice in family planning and how numerical and systematic targeting aimed at raising the numbers of contraceptive acceptors fundamentally undermines this concept in highland Chiapas. The Government of Mexico's pohcy aims within its Rqjroductive Health Programme (1995-2000) are to reduce the total fertility rate whilst promoting reproductive health services and femily planning choices. Though Mexico has seen a decline in its total fertility rate attributed to increased contraceptive use in urban areas, in rural parts the rate remains high. Consequently, the rural poor, and in Chiapas overwhelmingly indigenous populations, have become a major target of the Reproductive Health Programme. Monthly targets are set for clinics and family planning services are offered systematically every time a woman att^ds a clinic for whatever reason. Amongst the factors vMch must be accounted for in assessing femily planning provision in highland Chiapas are cuftural differences between mestizo providers and the indigenous target groups as well as local economic and political conditions. Presently, the state of Chiapas is higjily militarised and under the cloud of a low intensity war precipitated by the Zapatista uprising in 1994. The provision of any kind of heahh services is difficuh; under these situations, but more so whai one considers the distrust sown between some indigenous communities and the government v/ho provide the health services. This thesis examines the practicalities of inq)lemCTting a global pohcy at a local level and the constraints feced by both providers and intended recipients in the social context of Los Altos. Mindful of the care required in identification most people in this thesis (with the exception of a few well-known academics) appear under pseudonyms. m Acknowledgements I am indebted to many people for their contribution to the creation of this thesis. Firstly I want to thank those in Mexico who prefer not to be named - the church workers, academics, doctors and ordinary women and men. I am especially indebted to many women of Primero de Enero, Barrios Tlaxcala, La Hormiga and El Cerrillo. I owe special thanks to my supervisors: to Dr Andrew Russell for his constant support and encouragement and to Dra Luisa Elvira Belaunde for her continuous enthusiasm. My research was funded by scholarships from Durham University Anthropology Department, 1994-1997; Ehirham University Council Fund for Students Travelling Abroad, 1995; Emslie Homiman Scholarship, 1995; Radclijffe-Brown, 1998. I wish to thank many people at Ecosur, especially Drs David C. Halperin, Hector Ochoa Diaz Lopez, Elda Montero Mendoza, Austreberta Nazar and to Michael Fuller. Were it not for a chance e-mail encounter with Hector I may never have carried out fieldwork in Chiapas. For permission to interview their staff I thank at IMSS Drs Javier Cabral Soto, Luis A Martinez Guzman, Dionicio Angel Cortes and Manuel Toca Figueroa; at the SSA Dr Orantes; and at DIF Sra Gamboa . I am indebted to the health staff I interviewed. I would also like to thank Graciela Freyermuth, Barbara Cardenas, Micaela Ic6 Bautista and Gabriela Vargas-Cetina for their time and msight into local life. Thanks also to the women of the Grupo de Mujeres in Barrio Tlaxcala and to Dona Chely from Yach'il Antzetic for their time. Special thanks are due to Drs Carmelita Herrera Torres, Rosa Elva Cruz Pastrana, Jose Antonio (Tono) Pastrana Morales, and Armando Servin, who advised me in many ways and offered access to papers and statistics. Amongst others m Mexico to whom we owe a debt of thanks for support and friendship are La Familia Henriques Avila - Marisa, Mundo, Paula and Mateo; Irma Perez Luna and her son Rodrigo; Angelina Gomez Diaz and her sons Felipe, Jorge and especially Eduardo; Araceli Mellanes Rodas; Maria Cruz Hernandez; Maria Mendez Gomez; Rosa Velasco Perez; Margaret O'Shea; Robin Bain; Susana Scott; Elbrig and Cesar Mercedes Manchego and their children; Emily Ryan and Bill Flynn; Lupe, Normita, Beto and Lupita; Umberto Teyssier Jarillo and Carolina Netzahuatl Munoz; La Familia Diaz Guillen; Paula Bidle and Bud Moore; Teresa Ortiz and Tom Johnson. I thank my postgraduate friends at Durham for their support during the years that this research has taken to reach fruition: Hazel Tucker, Chris Fuller, Ole Hemtz, Amar Amason, Hulda Sveinsdottir and Rachel Baker. Last but not least I owe a debt of gratitude and a life-time supply of malt whisky to my compahero Tom Bartlett - research assistant, general dogsbody and onto de casa whose help and support has sustained me and our children, Sadie and Jamie, through the rigours and the pleasures of study and fieldwork. (English translations of Spanish texts quoted in the thesis are the work of Tom and myself All interviews were carried out in Spanish and again the translations were worked on by both of us.) We thank both our families (Thompsons and Bartletts) for their support. iv CONTENTS Abstract iii Acknowledgements iv Contents v List of Tables ix List of Plates x Introduction 1 PARTL THE RESEARCH AGENDA Chapter 1 Family Planning and the Individual: Rights, Needs and Informed Choice 9 Chapter 2 From Birth Control, Through Family Planning to Reproductive Health - Shifting Paradigms or Political Acumen? 22 Chapter 3 Mexico, Modernisation and Family Planning Policy 37 Global Ties and National Sovereignty 37 Economic Growth and Poverty - a neoliberal dilemma 39 Current Policy Formulation m Mexico 43 Family Planning Promotion: Targetmg Rural and Indigenous Areas 45 PARTH. TIDE RESEARCH AREA Chapter 4 Los Altos: The Setting and Methodological Factors 53 Political Infi-astructure 55 Working in a Conflict Zone Working in a Conflict Zone 57 Christmas 1997. Jesus ha nacido muerto. (Jesus is bom dead) 59 Collecting data in Los Altos 60 Intendewing Health Providers in Los Altos 62 The Interview Schedule 63 Interviews with local women around San Cristobal 69 Initiating the Snowball Effect 73 Deciding to carry out a small survey 75 The Survey 77 Chapter 5 Heallth Providers in Los Altos 83 Government Organisations 83 DIF (The National System for the Development of the Family) 85 IMSS-Solidaridad (Department of Social Security non-contributory wing) 87 The SSA (Mexican Ministry of Health) 89 Health coverage of the poblacidn abierta 92 Non-Governmental Organisations in Los Altos 94 Choice of Health Providers Available to the Poblacidn A bierta 95 The clinic in the rural highlands: a mestizo space m an indigenous world 95 The SSA Rural Health Centre 96 The IMSS Rural Medical Unit 97 Domination through supralocal institutions 100 PART m. SERVICE PROVISION IN LOS ALTOS Chapter 6 Government health service providers in Los Altos: constraints and quality of care issues 106 Behaviour and Discontent Amongst Doctors and Pasantes. 110 Local Politics and Physical Safety 118 Lack of resources 125 Infrastructure 128 Provider Constraints and Quality of Care: Effects of this on informed 129 choice Chapter 7 Contraceptive Provision in Highland Chiapas 131 Method Choice in Govenmient Clinics 131 Injectables and lUDs 132 Subdermal Implants 135 Sterilisation 136 Condoms 140 Natural Fertility Regulation Methods and Traditional 144 Fertility Regulating Methods Differences in Institutional Provision of Contraceptive Methods 147 Concientizacion 149 Chapter 8 Targeting of Family Planning Services in Highland Chiapas 154 Mision Chiapas de Salud Reproductiva 155 Ellos no saben nadaMestizo attitudes to the indigenous population 156 Reluctance to use contraceptives amongst the indigenous Maya 158 Systematic Offering and Numerical Targeting of Contraceptive Methods 162 Government Providers and Fixed Targets 166 The Consequences of Targeting 168 VI The Effects of Targeting on