University College London Institute for Global Health, London, UK.
University of California, Berkeley, USA.
BMC Pregnancy Childbirth. 2018 Jun 18;18(1):243. doi: 10.1186/s12884-018-1870-6.
Preventable 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.
We 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.
Of 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.
Stillbirths 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.
与非印第安人相比，拉丁美洲土著地区的孕产妇和婴儿死亡率仍然明显更高，服务提供方面的种族、性别和贫困不平等问题因服务提供不足而加剧。旨在改善围产期健康的标准方案对这些人群的死亡率影响有限，国家和国家统计数据以及对服务的评估与大多数土著民族居住的环境几乎没有关联。本研究通过考虑结构、文化和关系因素如何相互交织，使土著妇女和婴儿更容易受到发病率和死亡率的影响，从而寻求对原因和解决方案的新视角。
我们探讨了结构不平等和人际关系如何影响在墨西哥西北部的 Wixarika 社区中怀孕和分娩期间寻求护理的决策。在怀孕期间对 62 名妇女进行了访谈，并在她们的孩子出生后进行了随访。在 18 个月的时间里收集了观察数据，产生了五百多页的实地记录。
在接受采访的 62 名妇女中，有 33 名在家中分娩，没有熟练的医护人员在场，其中 5 名完全独自分娩。有 5 名婴儿在分娩过程中或之后不久死亡，我们在这里介绍其中 3 个案例研究。我们发现，服务提供的结构，即提供者有几天连续休假，加上医患关系不佳，以及有时非自愿地实施生物医学实践，这都阻碍了机构分娩。数据还表明，男性在支持伴侣分娩和分娩过程中发挥着重要作用。
在不必要的独自和无人协助的分娩背景下发生的死产和新生儿死亡是结构性暴力的表现形式：本可预防的发病率或死亡率是系统不平等和卫生系统薄弱的结果。这些结果反驳了一个常见的假设，即土著妇女避免机构分娩的选择是不合理的、文化上的或由于缺乏教育。相反，我们的数据表明，卫生系统中的机构安排和人际互动促成了可预防的死亡。除了长期的、文化上适宜的策略外，解决这些问题还需要对服务提供和资源分配进行重要但可行的改变。
