Indigenous women in Mexico's poorest states face health challenges on many fronts because of abject poverty, poor education, and a dire shortage of medical staff. Samuel Loewenberg reports.
It is not hard to find a case of a woman dying from childbirth in Chiapas. At one of the many pharmacies near to the city's main hospital, a worker tells of how her 26-year-old cousin began haemorrhaging after the birth of her second child, went into a coma, and died months later. "She had been going to the doctor every month", said the pharmacy worker, who asked that her name not be used.
Many women in this impoverished state at the southern end of Mexico do not even get the chance to see a doctor. Medically, the problem begins with a lack of prenatal visits, and then peaks catastrophically with the difficulty in accessing surgical care when complications occur during birth and in the days and weeks afterwards.
But the real culprits are poverty, insufficient education, poor transportation infrastructure, and a lack of medical staff. Overall, Mexico has made substantial progress in cutting its rate of maternal death. As a study in The Lancet recently noted, nationally maternal mortality has declined from 124 deaths per 100 000 livebirths in 1980, to 52 deaths per 100 000 by 2008. But the national numbers mask glaring inequalities, which continue to divide Mexico along lines of class, ethnicity, and geography.
In three of Mexico's poorest states, Oaxaca, Chiapas, and Guerrero, the health issues affecting women, especially maternal mortality, are far worse than in the rest of the country—in the case of Oaxaca, maternal mortality rates are nearly double that of the national average. Between 1995 and 2004, at least 778 women in the state died during pregnancy, childbirth, or postpartum. What has medical professionals and advocates concerned is that the loss of life indicated in these statistics is in most cases preventable. "These deaths shouldn't happen", said Ximena Avellaneda Diaz, the research director at the Rosario Castellanos Group for the Study of Women (GESMUJER), n Oaxacan women's non-governmental organisation (NGO).
Government health services have an "inability to adequately treat emergencies because of insufficient resources and staff", said Jose Ramon Pintor, the head of the state of Oaxaca's department of Gender Equality and Reproductive Health. Oaxaca has only one hospital bed per 1000 people, and in some areas, infant death rates are five times higher than in Mexico City. "We need more doctors and OBGYN specialists for rural communities", he said.
In the highlands of Chiapas, there is only about one doctor per 3000 people, which is about a third of what it should be, said Alied Bencomo of the state health service.
One major difficulty is transportation, or the lack of it. Some two-thirds of the population live in rural areas accessible only by bad roads, and the journey to a hospital can easily take 12 h. A woman facing an emergency needs to find a car, money for fuel, someone to drive the car, and someone to take care of her children, said Daniel Palazuelos, a doctor with Partners In Health who has worked in the mountainous Chiapas region for many years. "It's a chain of delays", he says. Even when a woman does arrive at a hospital, there might not be a bed available in the maternity ward, which is often well over capacity. All of this can mean the difference between life and death for a woman who has complications during and after childbirth.
Medically, the primary causes of maternal mortality are hypertension caused by eclampsia and pre-eclampsia, haemorrhages, and infections after surgery. This last cause is especially troublesome because it is in many cases unnecessary, says Cristina Alonso, the general director of the Luna Maya Birth Center in San Cristobal, who says that the hospitals do far more caesareans than is medically necessary. Women often do not get follow-up visits, so there is a big problem with post-birth infections.
A report by the John D and Catherine T MacArthur Foundation found that in Mexico "high rates of caesarean sections which are not medically indicated also lead to increased maternal mortality and morbidity". Between 1988 and 2000, 24·1% of births were caesarean sections, according to the report, when the standard rate should actually be 15%. At the same time, women who do need the surgical procedure might not be receiving it, the authors concluded. The MacArthur report also noted that while magnesium sulphate is the preferred treatment for eclampsia and pre-eclampsia, it "is not widely used in Mexico" due to "inadequate medical training" and shoddy supplies. Even in state-run hospitals, women are often required to purchase their own medical supplies and drugs.
Although many communities do have clinics, they often lack sufficiently trained staff. Most clinics are occupied by medical students who are doing a year of service. But this does not suffice, according to both government officials and women's advocates, who say that the students are often not sufficiently trained, do not speak the local Indigenous languages (of which there are dozens), and can be arrogant towards the women they are supposed to be helping. "The academic programme does not have an adequate standard. Universities need to educate their students better", said Pintor.
There are also cultural reasons for women's poor general health, particularly because of machismo. Most doctors are men, and macho attitudes at home can mean that family members forbid the woman to be seen by a man. Women are often reluctant to visit the clinic for their problems, even when they are pregnant, according to Maria Francisca Mendoza, the doctor in the small, primarily Indigenous village of San Juan Guelavia, an hour outside of Oaxaca's capital. "Women are scared that the men will get mad at them or hit them", she said. And when they do come, they are often too embarrassed to discuss their symptoms. The major health problem in her community, she said, is sexually transmitted diseases. The men, many of whom are migrant labourers, often refuse to use condoms.
Even without overt family pressure, Indigenous women are often hesitant to seek prenatal care. With little formal education and strong traditional and religious upbringings, many Indigenous women do not like the idea of seeing a male doctor. "It is difficult for any woman to have a man she has never met, to come and put his hands inside her vagina. It is especially hard for an Indigenous woman, who doesn't even touch herself", said Adriana Luna Castellanos, a doctor at the Marie Stopes reproductive health clinic in San Cristobal de Las Casas, Chiapas. Machismo has other consequences as well. Luna said that of the nine women she had seen the day before she was interviewed, three were for domestic violence. "Usually here domestic violence is not something that is questioned", she said.
When women do go to a prenatal visit, it is often an uncomfortable experience. Many doctors are indifferent to the women's socioeconomic conditions and give them recommendations that they cannot follow, says Luna. "The doctor says to the woman 'you have to relax', when she has to walk 2 miles for water or has to grind the corn for the tortillas. Or to sleep in a soft bed when she has a wooden bed. The advice the doctors give them is not appropriate for these people."
This advice is compounded by bureaucratic inefficiencies and poor patient interaction, which means that many women have little confidence in or understanding of the medical procedures they are told they must undergo. Many Indigenous women do not speak Spanish well enough to understand the doctors. Translation services are usually ad hoc, and in many cases are not available. And the results of a Pap smear may take half a year to arrive, if they are ever given to the patient at all. The result is that women have little trust in the medical system. "Yesterday this woman came in and had a urinary tract infection and I told her that she needed a Pap smear and she said no. She said because another woman had a Pap smear and she had a haemorrhage", said Luna.
At the same time, the much-lauded cash-transfer programmes to assist poor mothers might also be having an adverse affect. "Because now they pay you to have children. In many places, we see that woman want to have another kid for the money", said Luna. Poverty and lack of education has created another major killer in the form of cervical cancer. In Oaxaca it takes the life of one woman every 48 h, according to the Oaxaca Fund Initiative, an NGO. In Indigenous communities, where women do not have regular check-ups, the cancer is often not detected until it is at an advanced stage.
Complications from botched abortion attempts are another big problem, according to the MacArthur report. Abortion in Mexico is illegal, except in the capital city. Women with no other options will try informal remedies given to them by village healers, with sometimes disastrous consequences.
Education levels for Indigenous women are extremely low—most only go to school an average of 6 years, and nearly a quarter are married by the time they are 15 years. The average number of children they have is 5·6, which is more than double the national average. The probability that Indigenous Oaxacan women will die from childbirth is three times higher than that of non-Indigenous women.
The distrust that many women have learned to have for medical care makes improvement difficult. Current government initiatives are focusing on educating village midwives, because that is the first point of contact for many Indigenous women. But this is not a panacea, because many village women are reluctant to seek regular medical care until their problems have become critical, according to Moises Campo Torres of the General Hospital in San Cristobal. "Some women don't go to midwives, they stay and suffer in their homes. It is not until they are severely ill that their families bring them to the hospital and at that point it is too late."
The experience of disease and its consequences is sometimes the de facto teacher, said Campo, citing the cholera pandemic of the 1990s. "Cholera taught us where diarrhoea comes from. It taught people to boil water. Be cleaner. You could first go to communities where excrement could be found everywhere. Now, there are some communities with sewage systems."
Despite improvements, general infrastructure, including such basics as roads and transportation, remain poor in these regions. In the village of Betania, a few hours outside of San Cristobal, a mother haemorrhaged to death right in front of the clinic in 2008, according to Claudia Mijangos Guzman, who works in the local clinic. Problems include parasites, diabetes, hypertension, diarrhoea, respiratory problems, and malnutrition, the last of which is a major problem throughout the entire country.
Mexican's high consumption of junk food, and especially sugary soft drinks, is among the most frequently mentioned concerns for public health experts in these impoverished regions. Combined with a lack of education and poverty, that puts many pregnant women and their children at high risk of malnutrition. "People can't afford beans but they can afford Coke and chips", said Cristina Alonso, the general director of the Luna Maya Birth Center in San Cristobal.
Poor nutrition affects health at all levels. Oaxaca leads the country in birth defects, mainly because of a lack of folic acid, according to Pintor. Sometimes, the child has had malnutrition since the womb. Chronic anaemia is common for pregnant women. The government has started a programme to fortify common foods, like tortillas. Government attempts to provide fortified foods have had little success, said Pintor, because people do not like the way it tastes. Commercial producers also fortify foods, but they are too expensive for many poor people. In Chiapas, an estimated 25% of children under the age of 5 years are malnourished, said Campo.
The heavy restriction on immigration to the USA, where many Mexican men go to seek work, has increased the frequency of pregnancy and domestic violence, said Avellaneda of Oaxaca's GESMUJER. The sudden drop in remittances also affects the general health conditions of villagers, who depend on the funds sent by relatives.
"If you have family in the US that sends you money, then you can eat well. But if you don't then you eat beans, cheese, and corn tortillas", said Maricela Zurita Cruz, a 19-year-old girl who recently won a national award for her public health work with Indigenous women. "In my experience, woman do not make health a priority", said Cruz. "They do not realise that woman have the right to medical attention."