REPRODUCING INEQUALITY: AN EXAMINATION OF PHYSICIAN DECISIONMAKING DURING CHILDBIRTH IN MERIDA, MEXICO By Kelly Colas A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Anthropology-Doctor of Philosophy 2017 ! ABSTRACT REPRODUCING INEQUALITY: AN EXAMINATION OF PHYSICIAN DECISIONMAKING DURING CHILDBIRTH IN MERIDA, MEXICO By Kelly Colas Anthropologists have long recognized that health is directly shaped by political, institutional, and sociocultural context. This variability is especially apparent in examining medical-decision making within particular systems of health care; for example, who can make decisions and the type of decisions that may be made differs notably between settings. Childbirth is a salient window through which to explore the impact of broader social, cultural, and economic factors on decision-making, as the location of birth, interventions, and use of technology profoundly differ based on setting. Childbirth delivery method is a striking example through which to consider the impact of context on physician decision-making, as rates of Cesarean sections (C-sections) significantly vary worldwide. Mexico is an especially appropriate location to examine the decision for a C-section, as Mexico maintains the fourth highest C-section rate in the world. C-section rates have historically been the highest in the setting of the private hospital, as factors such as patient demand, financial motivation, and increased convenience have resulted in a C-section rate around 70%. C-section rates in Mexico are also increasing in the public hospital sector, where approximately 38% of deliveries are performed via C-section. It is unclear why C-section rates are surging in the setting of the public hospital, given that physicians are paid a set salary regardless of delivery method and work pre-determined shifts.! ! This dissertation presents the findings of a research project performed in 20142016, exploring physicians’ decision-making process for delivery method at two public hospitals in Southern Mexico. Utilizing participant observation and semi-structured interviews with 24 physicians at two public hospitals in Merida, Mexico, this dissertation examines how physicians’ understanding of institutional demands, medical hierarchy, and the patient population influences their decision for a C-section. Based on these findings, it is argued that physicians’ various positions within the medical institution, along with Mexico’s complex history class and race based discrimination, distinctly shape physicians’ perspectives on patient management. While physicians working in hospital administration emphasize the importance of meeting the state and federal government’s benchmarks for maternal health, senior and resident physicians are primarily concerned with ensuring a “safe” delivery within the constraints of the public hospital. Senior physicians focus on potential legal repercussions for an adverse outcome, while residents attempt to reconcile their medical knowledge with the strict hierarchy of these hospitals. I argue that an unintentional effect of the intense focus on outcome within the Mexican health care system is that as physicians in these hospitals struggle to avoid poor outcomes while facing limited resources and a heavy workload, they come to view technology like C-sections a crucial strategy for achieving a safe birth. Ultimately, I posit that Mexico’s system of stratified health care has resulted in magnifying existing social, cultural, and economic disparities, as patients’ needs are relegated as secondary to bureaucratic demands. ! Copyright by KELLY COLAS 2017 ! In memory of my grandfather, Raymond Colas, who taught me the value of persistence, passion, and hard work. v ! ACKNOWLEDGEMENTS First, I would like to thank all of the research participants in this study, who graciously welcomed me into their lives and candidly shared their experiences with me. I am both honored and grateful for their honesty and openness. I would also like to thank my doctoral committee; their guidance and feedback for this project has been invaluable. I would like to thank Dr. Masako Fujita for her keen insight regarding the research methodology and analysis of this project. Thank you to Dr. Jacob Rowan for providing a clinician’s perspective and for his unwavering support of this project. I am so grateful for the feedback of Dr. Lucero Radonic; her perspective on the social dynamics in Latin America was instrumental to this project. Lastly, thank you to Dr. Linda Hunt, my committee chair. Words cannot express how deeply grateful I am for her support, mentorship, and feedback over the last five years; I feel unbelievably fortunate to have her as a committee chair. This project would not have been possible without her. I must also thank everyone who supported me throughout the doctoral dissertation process. Thank you to Dr. Justin McCormick and Bethany Heinlen who offered me the incredible opportunity to pursue a degree in both anthropology and medicine. I am so grateful for their continued support and flexibility; thank you for working so hard to ensure my success in this program. I would also like to thank my undergraduate mentor, Dr. Vania Smith Oka, who first sparked my passion for anthropology and offered valuable feedback on this project over the years. Finally, I am forever indebted to my friends and family for their limitless encouragement throughout this process. Thank you to Rachel for believing in me from the start of this journey and for patiently listening throughout it. Thank you to McKenna vi ! for the unconditional support over the last few years; this process would have been considerably less fun without you! Thank you to my grandparents, Marty, Mary Lou, and Roger. I would never be in this position without you. Most of all, thank you to my parents, Mary and Tim, for believing I was capable of accomplishing anything. I am grateful for the countless hours they have spent listening about this project and for standing by me through every success and failure. ! vii ! TABLE OF CONTENTS LIST OF TABLES………………………………………….……………………….. xi KEY TO ABBREVIATIONS………………………...………………………….….. xii Introduction…………………………………………………………………..…........ Summary of Dissertation Chapters……...…………..……………………..……. 2 6 Chapter 1: Neoliberal Ideology in Health Care: The Impact of Institutional Demand on Physician Decision Making……………………….……………………………… Introduction…………...…..….……………………………..………………….. Background: The Expansion of the Neoliberal Ideology in Health Care.……... Quantifying Health: Neoliberalism and the Use of Metrics ………………….... The Production of Data and Medical Guidelines: Erasing the Individual Patient……………………………………………………………………. Metrics in Medicine: The Impact of Outcome Measurements on Physician Decision- Making.,……………………………………………. Health Care in Latin America………………………………………...……....... Neoliberal Reform and Stratified Health Care in Mexico ………...……...……. Conclusion……………..……………………………….………………...….…. 10 11 12 15 16 17 20 21 24 Chapter 2: Medical Decision-Making in Childbirth……….…………....……..…….. Introduction……………………………………………….…………...….…….. Features of Medicalized Childbirth ………………………….……………....…. Social, Cultural, and Economic Agency and Decision Making during Childbirth. ……………………………………….…………...….……………... Childbirth and the Neoliberal Agenda………………………………………….. Challenging Physician Neutrality: Decision-Making and Technology……….... Physician Decision-Making in the Public Hospital System………………..…… Conclusion……………………………...………………………………...…...... 26 27 28 Chapter 3: Settings and Methods…………..………………………………….......... Settings………………………………………..……………………………….. Introduction…………………………..………………………………………... A Demographic Overview of Yucatan, Mexico…………..…………..……….. Maternal Health in the Yucatan……………………………….………...……... Medical Training in Mexico …………………………………………..…..…... Site Locations…………………………………..…………………..…..……… (i.) Hospital General……….…………….…..…….…...……..….. (ii.) Hospital Pequeño……...………………....………………..…. Methods…………...………….………………….………………….……...….. Participant Observation…………….…………………………………… Semi-structured Interviews ………………………………...…..………… Data Analysis……………………………………..……………………….….... 40 41 41 42 46 49 52 53 55 57 58 59 63 viii ! 30 31 33 36 38 Chapter 4: “Here we don't really treat low-risk pregnancy as low-risk:” Physicians’ Perceptions of C-sections……………………………………….………………....... Introduction……………..…….……………………………….…………….… Why C-sections Occur: Physician Perspectives on Delivery Method…..…..… Childbirth as Risk ………………………………….…………………...……... Monitoring and Guidelines: Mitigating Risk ……...………………...………... Construction of the “Medical Imaginary:” The Influence of Institutional Context on Physician Perception……………………..………………...……… C-sections as Risk Management: Senior Physicians’ Perspective of Institutional Context……………………………………………...…………... “They Don’t Give Women a Chance:” Residents’ Perspectives of Institutional Context……………………………...……………………………...………… Conclusion………………………………………………………………..…... Chapter 5: “It’s not really a punishment; it’s an incentive to do better:” Data Performativity, Responsibility, and Blame at Hospital General and Hospital Pequeño ………………………………………………………………….... Introduction……….……………………………………………………………. Data Performativity ……………………………….…………………………… Countdown to 2030: Mexico and Maternal Mortality……………….………..... Metrics and Evaluations at the Yucatan Ministry of Health ……………….….. Good Behavior and Good Numbers: Administrative Physicians’ Perceptions of Metrics and Responsibility………………………………………………....... Physicians’ Perceptions of Responsibility and Institutional Goals……….……. Avoiding “La Demanda”: Senior Physicians’ Perspectives on Outcome……… Medical Hierarchy and Blame: Residents’ Perceptions of Institutional Stress… Conclusion……………………………………………………………………… Chapter 6: Physicians’ Expectations for Patient Behavior: Blame through Microaggresions……………………………………………………………………... Introduction………….…………………………………………………………. Intersectionality as a Theoretical Framework …………….…………………… Moral Regimes and Microaggression in Childbirth……….……………….…… Controlling Reproduction: Responsible Family Planning in Latin America…… “We have people here without very much culture:” Women as Uncontrollable Reproducers………………………………...………….. Discipline for Excessive Reproduction…………………………………. Microaggressions and Birth Control Use: “If I were you I’d never get pregnant again” …………………….…………….…………………….. Cooperation: Physicians’ Expectations for Patients during Labor and Delivery.. Accepting the Pain of Childbirth……………….……………………….. The Uncooperative Patient: Microaggressions Towards “Disruptive” Patients………………………………………………………………… Vertical and Horizontal C-section Scars: Inscribing Risk…….………………... “They might not bathe for a week:” Physician Perspective of C-section ix ! 66 67 68 70 72 74 76 78 83 85 86 87 88 90 93 100 103 107 114 116 117 118 119 121 123 125 127 131 131 133 137 Incisions………………………………………………………………….. Vertical C-section Incisions as Corporeal Microaggressions……………. Conclusion……………………………………………………………………… Chapter 7: Discussion and Conclusion: Implications of the Neoliberal Ideology on Childbirth …………………………………………………..………………………. Introduction………………………..…………………...……………………… Why C-sections Occur: Taking a Closer Look at Physician Beliefs.......….…... Data Performativity and Bureaucratic Demands: Creating New Realities Through Quantification………..………………………………………………. Deepening Disparity: The Effect of the Neoliberal Ideology in Health Care on Vulnerable Populations…………………………………………….….…….… The Influence of the Neoliberal Agenda on Health Care: Who Benefits?….…. WORKS CITED.………………..……………………………………...…………..... x ! 138 143 148 150 151 153 154 156 157 161 LIST OF TABLES Table 1: Demographic Information of Research Participants………..…………………63 xi ! KEY TO ABBREVIATIONS MDG: Millennial Development Goal MMR: Maternal Mortality Rate OB/GYN: Obstetrics and Gynecology SSA: Ministry of Health (Secretariat de Saludabridad y Asistencia) Toco: slang used by physicians for tococirugía, the birth ward in Hospital General xii ! ! Nunca Desistas Cuando vayan mal las cosas como a veces suelen ir, cuando ofrezca tu camino sólo cuestas que subir, cuando tengas mucho haber pero mucho que pagar, y precises sonreír aun teniendo que llorar, cuando ya el dolor te agobie y no puedas ya sufrir, descansar acaso debes pero nunca desistir. Don’t Quit When things go wrong as they sometimes do, when the path you’re trudging seems to be all uphill, when your funds are low but the debts are high, and you need to smile but you have to sigh, when the pain already overwhelms you and you can no longer suffer, rest if you must, but don’t you quit. --Rudyard Kipling Poem on the wall of the OB/GYN Interns’ Break Room at Hospital General 1 ! ! Introduction 2 ! ! Anthropology has long recognized that medical decision-making is directly influenced by the political, institutional, and sociocultural contexts that it occurs within (Baer, et al. 2003; Good 1993; Kleinman, et al. 1978). Who is able to make decisions and the types of decisions that an individual or group are able to make varies immensely depending on social and cultural setting (Davis Floyd and Davis 1996; Jordan and Davis-Floyd 1993). A critical component in understanding how medical decisions are made is an examination of the broader system of health care that these decisions occur within and the assumptions that a given health care system is built upon. Within the last several decades, social scientists have observed that a “neoliberal” ideology underlies many health care systems, transforming how health is understood and how care is administrated. David Harvey (2007) defines neoliberalism as political and economic practices that maintain that “human well-being can be best advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free makes and free trade” (11). Harvey writes that the role of the state in this scheme is to facilitate these principles, rather than to intervene or provide services. The underlying premise of the neoliberal ideology is that through minimal interference by the state, economic competition will be spurred, maximizing efficiency and profit. Applying these principles to the field of health, systems of nationalized health care have been dismantled over the last several decades, replaced by privatized health care. Proponents of this model of health care assert that through privatizing health care and reducing the state’s role in administering health services, health care will function as a commodity to be sold to 3 ! ! patients, who will act as “rational” consumers, selecting the best quality service at the lowest cost (Mulligan 2014; Rylko Bauer and Farmer 2002). However, critics point out that the neoliberal ideology’s emphasis on generating profit holds negative implications for both patients and providers. Scholars have noted that one effect of creating a system of health care that prioritizes financial interests is that physicians’ ability to make decisions within this system becomes increasingly constricted (Hunt, et al. 2017; Magrath and Nichter 2012; Oldani 2010). In recent years, researchers have observed that physicians working in health institutions based on neoliberal principles are further limited in their decision making abilities through this system’s increasing reliance on metrics to quantify particular health outcomes (Adams 2016; Pfeiffer and Nichter 2008). While the medical community often views such measurements as reflecting indisputable facts, anthropologists have turned a critical lens towards the way in which such data is produced, observing that metrics rarely correlate with complex social realities (Erikson 2012; Sangaramoorthy and Benton 2012). Rather than relieving health disparities, social scientists note that the use of metrics to quantify health outcomes serves to exacerbate existing inequalities, as such measurements largely fulfill institutional requirements rather than addressing social, economic, and political injustices (Biruk 2012; Wendland 2016). A greater understanding is needed of the mechanisms through which these institutional requirements influence physicians’ understanding of their work and their perspectives on the decisions that they are able to make. Mexico provides a particularly intriguing setting in which to examine this impact, as Mexico’s recent implementation of health policies based on neoliberal tenants has strengthened a tightly stratified system of 4 ! ! health care (Knaul and Frenk 2005). While physicians working in the public hospital sector are expected to meet institutional demands like particular numbers for mortality and morbidity, the underfunded public hospital system results in a challenging work environment for physicians, as they often work with a large patient volume and limited resources (Mills 2006; Smith-Oka 2013a). Childbirth is a particularly salient window through which to examine the impact of broader social, cultural, and economic context on physician decision-making. While childbirth is a universal physiologic event, the setting in which childbirth occurs is critical to consider, as the way in which birth is practiced varies immensely crossculturally (Jordan 1992). Additionally, within the scheme of international health, particular metrics of childbirth, such as infant and maternal mortality rates, hold immense social and political meaning, as such metrics are often viewed as a mark of the relative success or failure of a nation’s health system (Oni-Orisan 2016; Wendland 2016; Williams 2016). A growing area of interest within the field of maternal health is a focus on Cesarean section (C-section) rates, as a host of negative medical implications for the mother and infant have been associated with the excessive use of C-sections (Belizán, et al. 2007; Burt, et al. 1988; Silver, et al. 2006). Yet, C-sections are a complex area of investigation, as rates of C-sections vary widely depending on the setting (Betrán, et al. 2016). This impact is particularly visible in Mexico, a country with the fourth highest Csection rate in the world as of 2012 (Gibbons, et al. 2012). C-section rates have historically been the highest in the setting of the private hospital, where researchers have identified factors such as patient demand, financial motivation, and increased 5 ! ! convenience for physicians to be responsible for a C-section rate of nearly 80% (Diniz and Chacham 2004; Hopkins 2000; Klimpel and Whitson 2016; Suárez 2012). However, in Mexico, C-section rates continue to increase in the public hospital sector where approximately 38% of deliveries are performed via C-section (Suárez 2012). It is unclear why C-section rates continue to surge in the setting of the public hospital, given that physicians are paid a set salary regardless of delivery mode and work predetermined shifts. This dissertation will examine factors impacting physician decision-making regarding labor and delivery at two public hospitals in Yucatan, Mexico, a state with the second highest number of indigenous language speakers in Mexico (INEGI 2010: 81). It will address existing gaps in the literature by utilizing ethnographic methods to explore how physicians working within obstetrics and gynecology (OB/GYN) understand the requirements of the public hospital system and how this perception influences their decision-making process regarding childbirth delivery method. Ultimately, through this decision-making process, I will illuminate some of the implications for marginalized groups of utilizing neoliberal model in health care, exploring how existing social, cultural, and economic hierarchies are reproduced through this system. Summary of Dissertation Chapters In Chapter 1, I will explore the features of a neoliberal health system, observing the effects that decentralizing medical services have on health infrastructure and care. Noting the increasing importance of metrics in a neoliberal health system, I observe how such outcome measurements profoundly influence physicians’ decision-making and obscure intricate social, political, and economic dynamics that shape patients’ health. I 6 ! ! then discuss changes to Mexico’s health care system, detailing the effects of a stratified system of health care on physicians and patients, particularly within the underfunded public hospital sector. Chapter 2 examines childbirth as a cultural phenomenon. I discuss critical features of medicalized birth, noting the underlying assumption that birth is an inherently risky event. Observing the importance of political, social, and cultural factors in childbirth, I note the different levels of agency patients may have in participating in the decision-making process. I explore the importance of context on physicians’ decision-making, utilizing delivery method as an example through which this influence can be examined. Lastly, I introduce the issue of a high C-section rate in Mexico, discussing previous literature that has explored the impact of institutional context on decisions for a C-section. Chapter 3 introduces the historical context of the Yucatan state in Mexico, considering the implications of centuries of race and class based discrimination on current social dynamics, particularly as this pertains to women’s health. I present my research sites in Merida, discussing how I selected each hospital and the important features of each location. I examine the work environment of each hospital and detail a typical day for physicians at each hospital. This chapter also reviews the methodology of this project, as I explain the qualitative approach I utilized to capture multi-dimensional data for this project. I conclude by discussing the data analysis techniques that I employed. Chapter 4 examines physicians’ perspectives on why C-sections occur in their respective hospitals. While all physicians at these hospitals understand birth as a high- 7 ! ! risk event, senior physicians and residents diverge in their views of how this risk should be managed. Drawing on Mary Delviccho Good’s (2007) theory of the “medical imaginary,” I observe how C-sections become the “common sense” option for senior physicians, while residents remain more critical in their views of how deliveries at their hospitals are managed. Chapter 5 explores the impact of institutional structure on physicians’ understandings of their work environment. I contend that administrative physicians, senior physicians, and residents contend with varying anxieties about their jobs, shaped by their situated perceptions of the repercussions for a “bad outcome.” While administrative physicians directly consider the implications of poor statistics on each hospital’s funding and personnel, senior physicians and residents’ concerns pertain more to their immediate work environment. I discuss senior physicians’ anxiety over potential lawsuits, while residents primarily focused on navigating the strict medical hierarchy and overwhelming workload in Hospital General and Hospital Pequeño. I explore the way in which C-sections become a mechanism for physicians’ to manage the challenges of their environment, as they perceive C-sections to be a less important metric to hospital administrators. Chapter 6 explores how the nature of Mexico’s public hospital system impacts patients. Utilizing the framework of intersectionality theory, I examine the way in which social, cultural, institutional, and historical variables coalesce to shape clinical encounters at these hospitals. Drawing on Vania Smith-Oka’s (2015) concept of microaggressions, I observe how these factors structure physicians’ negative characterization of patients and harsh interactions between physicians and patients . I 8 ! ! utilize C-section incisions as a physical representation of the larger social marginalization that patients face. I contend that ultimately, Mexico’s public health system creates deeper disparities as the needs of patients are cast aside for those of health care institutions. ! Chapter 7 discusses the findings of this research in relation to other anthropologic literature. Situating an examination of decision-making within a specific sociocultural and institutional context is critical in understanding physicians’ perspectives. While senior physicians see C-sections as an important tool to manage the large volume of births in their hospitals, residents express criticism towards senior physicians for rushing to the decision of C-section. In order to comprehend why physicians of different training levels may hold varying perspectives on patient management, it is crucial to explore how they view the institutional structure that they work within. Utilizing Erikson’s (2012) concept of data performativity, I argue that physicians’ position within the medical system profoundly influences their understandings of the outcome they are expected to achieve, and this perception subsequently shapes their actions. Finally, building on Morgan and Roberts’ (2012) discussion of moral regimes, I argue that Mexico’s history of race and class based discrimination, along with the disenfranchising environment of the public hospital system, exacerbates physicians’ negative characterizations of the patient population. ! ! ! ! ! 9 ! ! ! ! ! ! ! ! ! ! Chapter 1: Neoliberal Ideology in Health Care: The Impact of Institutional Demand on Physician Decision Making 10 ! ! Introduction Decision-making is a critical aspect of the health experience cross-culturally. Within nations practicing the highly technologically dependent system of medicine, often referred to as “biomedicine,” physicians are essential in the decision-making process (Clarke and Shim 2009; Gaines and Davis-Floyd 2004). As discussed in the introduction to this dissertation, the dominance of a neoliberal agenda within the last several decades has profoundly impacted how physicians make decisions. As physicians work under increasing pressure to generate profit and efficiency, researchers have noted that physicians’ autonomy to make decisions continues to diminish (Hunt, et al 2017; Oldani 2010). In the last several years, health systems have grown increasingly reliant on particular data to create treatment guidelines for patients and to track subsequent health care outcomes (Adams 2016; Sangaramoorthy and Benton 2012). Examples of such measurements utilized that assess physicians include metrics such as the percentage of preventative health services administered to patients, the number and type of procedures performed, and the number of patients with controlled chronic conditions. On the level of hospitals or private practices, such metrics might include rates of complications, infections, and mortality. If physicians or health care systems fail to meet such measures, they are met with repercussions such as decreased reimbursement from insurance agencies, changes in personnel, or in extreme cases, job loss (Magrath and Nichter 2012). While these metrics may not accurately reflect the way in which health care is practiced and experienced in a particular setting, social scientists have noted that these numbers profoundly shape the behaviors of individuals within that system, carrying enormous 11 ! ! political, social, and financial implications (Biruk 2012; Erikson 2012; Oni-Orisan 2016). This chapter will explore how the neoliberal ideology is utilized in health care, considering how a system based on financial gain, productivity, and individual responsibility reshapes the experience of both patients and providers. Mexico is a particularly intriguing setting in which to examine the impact of such policies. Along with many other Latin American nations, Mexico’s health care system has been restructured within the last several decades with the strengthening of health policies based on neoliberal ideals (Frenk, et al. 2003). I will note that through tracking outcomes like financial gain and efficiency, the recent reliance on metrics continues to strengthen the neoliberal agenda, as these numbers come to be viewed as important indicators of a health system’s success. I will examine how changes to Mexico’s health care have altered this system, noting that a stratified system of health care creates profoundly different experiences for both patients and providers. Background: The Expansion of the Neoliberal Ideology in Health Care The United States’ valorization of market principles in health care has profoundly influenced how health care is practiced in many regions of the world, including Latin America (Pfeiffer and Chapman 2010; Stocker, et al. 1999). This system of health care gained additional traction under the conservative Reagan and Thatcher administrations in the early 1980s. This view maintains that a free and unregulated market is central to democracy and financial growth. Operating under the premise that the market will govern itself based on the principles of competition, financial incentive, and personal responsibility, neoliberalism views governmental regulation as unnecessary and a hindrance to the progress of the market (Harvey 2007). The neoliberal ideology 12 ! ! advocates for a profound reduction in public services, reflecting the belief that the private sector will most effectively increase profit and enhance productivity (Homedes and Ugalde 2005). Applied to the realm of health care, this view holds that the private sector should operate in the model of a capitalist business: companies sell health care as a commodity, physicians administer services, and patients act as customers, making responsible and informed decisions (Mullingan 2014, Rylko- Bauer and Farmer 2002). In the last several decades of the 20th century, health policies based on the neoliberal ideology have been increasingly implemented in the international realm, most notably Latin America (Homedes and Ugalde 2005; Iriart, et al. 2001; Velázquez Leyer and Pablo Ferrero 2016). However, in both the United States and Latin America, the use of a health system based on generating profit has been widely criticized for its effects on both patients and physicians. By prioritizing revenue over patient wellbeing, the roles of physicians and patients have fundamentally transformed. Social scientists have observed that the authority of physicians is increasingly replaced by the demands of pharmaceutical companies, insurance agencies, and private investors (Elliott 2010; Oldani 2004; Rylko Bauer and Farmer 2002). The recent introduction of measures like electronic health records, pay for performance programs, and quality performance measurements continue to limit the decisions that physicians are able to make (Hunt, et al. 2017; Magrath and Nichter 2012; Oldani 2010). As physicians must meet the criteria established by these measures, they are subject to working for market demands, rather than making decisions based on their own intuition or training. In addition to the impact of a profit centered health system on physicians’ work environment, scholars note that patients are also affected by such policies. Researchers 13 ! ! have observed that a major implication of replacing systems in which health care is a right with systems that treat health care as a business has been that vulnerable populations disproportionately shoulder the poorest health outcomes, while multinational corporations increase their profit (Armada and Muntaner 2004; Chary and Rohloff 2015; Stocker, et al. 1999; Unger, et al. 2008). Paul Farmer (2003) asserts that patients with the greatest socioeconomic resources are able to afford quality care, while individuals who are already marginalized cannot. Massive health disparities continue to exist in Latin America, with disenfranchised groups such as indigenous individuals maintaining the highest rates of morbidity and mortality (King, et al. 2009). Yet, scholars note that the way in which neoliberalism increases disparities is at times insidious. Neoliberalism places an emphasis on the role of the individual; individuals are conceived as freethinking, autonomous units participating in the market economy (Harvey 2007). Accordingly, this belief operates on the assumption that individuals will behave rationally, engaging in behaviors that promote their wellbeing (Mulligan 2014). Although such decisions are rarely considered within broader social, economic, and political hierarchies, the neoliberal ideology maintains that individuals are accountable for all subsequent outcomes. Ericson and colleagues (2000) write, “Within a regime of responsible risk taking, all differences, and the inequalities that result from them, are seen as a matter of choice. Conceived as a choice, inequality is also seen as inevitable” (533). Similarly, Farmer (2006) calls this naturalization of inequality the “geography of blame,” observing that rather criticizing the larger political and economic structures that result in certain groups disproportionately suffering from illnesses like AIDs and tuberculosis, poor outcomes and health disparities come to be viewed a result 14 ! ! of cultural idiosyncrasies and personal choice. In recent years, many health care systems increasingly rely on numbers and metrics to manage health care subjects (Abadia and Oviedo 2009; Mulligan 2014). In the next section, I will review how such metrics are produced and how meaning becomes attached to these numbers. I observe how the obsession with metrics further disenfranchises vulnerable populations, as complex social dynamics are reduced to numbers and interventions are designed based on efficiency and profitability rather than health needs. Quantifying Health: Neoliberalism and the Use of Metrics In the last several decades, the use of numerical data to inform and direct health decisions has become an integral component of the neoliberal agenda. This data is frequently utilized in the form of guidelines and outcome measures, shaping the way in which health care providers view patients and the decisions that they make. These numbers are often presented as neutral and unquestionable facts, assumed to provide a realistic portrayal of health (Biruk 2012; Sangaramoorthy and Benton 2012). However, social scientists have begun to scrutinize how such numbers are produced and utilized, as Vincanne Adams (2016) writes, “number crunching and metrics… tell stories about what those who produce them and what those who rely on them care about most” (9). Like Adams asserts, while metrics may not accurately reflect individuals’ health, the use of such numbers profoundly shape health encounters. In this section of the chapter, I will discuss two important mechanisms through which data is utilized in clinical interactions, and the impact of these numbers on health care decisions. 15 ! ! The Production of Data and Medical Guidelines: Erasing the Individual Patient Guidelines implemented in biomedical practice are an example of how numbers take on meaning in the context of clinical encounters. Such guidelines are frequently based on evidence-based medicine (EBM); randomized, double blind clinical trials, viewed by the biomedical community as the “gold standard” for providing evidence (Lambert 2006; Wendland 2007). Joseph Dumit (2012) writes that in these trials, one group is randomly given a specific treatment and the other group is given a placebo. The two groups are then compared to determine the effects of that treatment, which often entails considering the reduction of potential risk due to receiving treatment. The comparison of a treated group to an untreated group often yields predictable results: the treated group will demonstrate some alteration in their state of health, although such differences might be incredibly minute. This variability can be additionally magnified as the outcome of such studies is extrapolated to a population level (Rockhill 2001). Beverly Rockhill (2001) notes that one major problem with the application of this data is that it is often applied to individual patients. She points out that such studies are utilized to project potential risk of an adverse event on a population level, making it difficult to meaningfully apply this data to individual patients. She writes, “…a risk factor is a probabilistic concept that applies to an aggregate of individuals, not to a specific individual” (2001:365). Utilizing computations of risk at the population level for individual cases neglects to consider the specific variables of an individual in question. Thus, Dumit (2012) notes that the use of data from these trials has resulted in shifting physicians’ approach from determining a diagnosis based on individual cases to referring to this data for answers. Dumit observes, “…it meant that the treatments were so similar 16 ! ! in effectiveness that no doctor or patient would be able to experience the difference but instead would have to rely on the results of the clinical trail to tell them which drug was better” (2012:4). Thus, physicians are no longer compelled to examine the individual patient that they are treating, as they can refer to guidelines based on such studies. The use of guidelines based on EBM studies to diagnose and treat individual patients becomes additionally problematic as insurance companies and hospital systems require physicians to manage their patients, thereby treating patients according to population level data, rather than as specific individuals (Hunt, et al. 2012; Magrath and Nichter 2012). Metrics in Medicine: The Impact of Outcome Measurements on Physician DecisionMaking In addition to relying upon guidelines to assess patients, social scientists note that data becomes critical in the assessment of particular health care systems and those working within it. As health care systems based on the neoliberal ideology focus on enhancing profit and productivity, quantifying particular outcomes is a method to measure this progress and to make informed business decisions. With the widespread implementation of technology in the field of health care, hospitals, insurance agencies, and private organizations are more easily able to track and quantify particular outcomes (Clarke and Shim 2009). Examples of such outcomes include measurements for physicians like the percentage of preventative health services administered to patients and the number of patients with controlled chronic conditions. On the level of hospitals or private practices, such metrics might include rates of complications, infections, and mortality. However, social scientists question if the way in which these metrics are produced is 17 ! ! a meaningful representation of the social, political, and cultural dynamics that shape health. Rather than considering the complex environment in which health care is practiced, social scientists observe that extracting particular data for metrics often decontextualizes the setting that this data was produced within. Sangaramoorthy and Benton (2012) note that entirely new categorizations can arise depending on what is measured, writing, “both ‘counters’ and ‘counted’ co-construct categories of identity through use of enumeration” (228). Claire Wendland (2016) illustrates this idea in her study of maternal mortality statistics in Malawi. In examining how maternal mortality calculations are generated, she observes that certain criteria like gross domestic product (GDP), presence of skilled birth attendants, and national fertility rate are utilized in calculating maternal mortality rate, but other critical elements such as political stability and quality of care remain unconsidered. Wendland asserts that the indicators included in the calculation effectively reflect the priorities of those who require this data, rather than providing an effective solution to alleviate the structural injustices that create preventable maternal death. Thus, it is crucial to consider the political, social, and institutional setting that particular data is produced within, rather than a neutral number. While metrics may not accurately reflect the complex cultural factors that create health realities in a given setting, social scientists contend that it is critical to examine how such measurements influence physicians’ behavior and decisions within a clinical encounter. For example, Hunt and colleagues (2017) note that electronic health records (EHRs) structure interactions between physicians and patients, as the questions required by the EHR come to dominate the medical encounter, replacing the physician’s opinion or intuition. The authors suggest that the physician increasingly functions to meet the 18 ! ! demands of a particular institution, rather than as a medical expert (2017:15-16). In addition to fulfilling particular metrics, scholars note that the way in which health care providers and administrators perceive the importance of metrics also reshapes health encounters. Erikson (2012) contends that the emphasis on certain statistics deeply influences how health care is delivered. She observed that physicians at a hospital in Germany altered the entry of infant mortality statistics to avoid losing business due to high infant mortality statistics, by omitting cases that were unfavorable for hospital data (377). Similarly, Oni-Orisan (2016) found that physicians in Nigeria altered their practice of medicine based on metrics that they perceived to carry political importance. Noting that a low maternal mortality rate was emphasized politically, Oni-Orisan found that young doctors felt that older physicians in the hospital changed their medical practices to achieve particular statistics. In one such instance, a young doctor felt frustrated that an older physician with political ties admitted a patient with no medical indications, and speculated that the older doctor was attempting to bolster the hospital’s statistics through admitting a healthy patient (2016:97). Oni- Orisan noted that maternal mortality statistics carried great political significance, and was utilized as a marker of the success of failure of leaders in the government. As Adams (2016) notes, the intention of critiquing metrics is not to exclude their use altogether or to implicate that all numerical data is meaningless, but rather, exploring the way in which data is produced and applied lends greater insight towards what such numbers really tell us. Observing that metrics may not necessarily reflect the health experience of those within a particular system is critical in understanding how these numbers are utilized and their effect on those within this system. As Erikson and Oni- 19 ! ! Orisan point out, physicians’ perceptions of such requirements can profoundly impact their actions. Thus, this data may serve as a better reflection of the priorities of the parties that require it rather than actual health needs. Biruk notes an implication of this system is that it “effectively manages, rather than eradicates” striking health disparities (2012: 348). Yet, what are the mechanisms through which such inequalities are managed? How do physicians perceive the constraints of their work environment? How do they work within these challenges, particularly in settings of limited resources? Health Care in Latin America Latin America is a particularly salient setting in which to examine these questions, as within the last several decades, health policies premised upon the neoliberal ideology have largely replaced formerly universal systems of health care. Following the Latin American Debt Crisis of 1982, numerous nations in South and Central America were forced to seek financial assistance from the International Monetary Fund (IMF) and World Bank (WB). In order to receive funds to assuage this debt, the IMF and WB created economic, political, and health care policies for these countries, many of which favored neoliberal principles, profoundly reducing social services (Iriart, et al. 2001; Stocker, et al. 1999). Thus, Latin American countries, most of which maintained a long history of universal health services, marked a major change as they incorporated systems of private insurance. Similar to the implementation of the neoliberal agenda in health policy in the United States, the core tenants of this shift in Latin American health care consisted of decentralizing state health care programs and privatizing insurance, with an emphasis on consumer choice, individual responsibility, and documentation, expanding profits and efficiency (Homedes and Ugalde 2005). However, scholars have noted that 20 ! ! health policy built on neoliberal ideals has had disastrous effects in many health systems, resulting in unaffordable co-pays, weak infrastructure, and poor quality of service (Abadia and Oviedo 2009; Mills 2006; Mulligan 2014; Rylko Bauer and Farmer 2002). Neoliberal Reform and Stratified Health Care in Mexico In the last twenty years, reforms to the Mexican health system have incorporated these neoliberal tenants. While Mexico has historically provided health insurance for waged workers, the unemployed sector of the population could seek health care by either paying out of pocket for private care or receiving services through the Ministry of Health (SSA). In 2004, under the System of Social Protection in Health, a new form of insurance called Seguro Popular was created to extend health care for those who did not qualify under worker’s insurance or could not afford private health care, providing limited coverage for particular procedures, diagnoses, and medications (Velazquez Leyer and Ferrero 2016:123). Mexico currently maintains several levels of healthcare: 1. Private insurance; 2. Servicios!Sociales!de!Los!Trabajadores!del!Estado!(ISSSTE) for government employees; Instituto Mexicano del Seguro Social (IMSS) and Instituto!de! Seguridad!for!waged!workers!3.!A!separate!system!of!insurance!for!individuals!in! the!Mexican!Military!or!Navy;!4. Seguro Popular through SSA institutions for unemployed or self employed sectors of the population. An important implication of the changes to Mexico’s public health system implemented in 2004 is how this system is funded. Seguro Popular was designed as a partially subsidized system of health care, meaning that Seguro Popular is paid for by the federal government, the state government, and co-pays from individuals above a certain income bracket (Knaul, et al. 2012). The financing of Seguro Popular is incredibly 21 ! ! complex, but was created in a demand-based model, meaning that states with more enrollees receive more funding (Frenk 2005). Julio Frenk (2005), the former Mexican Minister of Health, writes that the federal government’s contribution is calculated from a formula based on the number of families enrolled in Seguro Popular, a health-needs adjusted component, and the performance of the state’s health system (1471). While it is unclear what the “performance” of the state’s health system entails, an administrator at the Ministry of Health in the Yucatan explained to me that the hospitals in the state of the Yucatan possess a Department of Quality Control, in which particular data about each hospital is generated and sent to the state’s Ministry of Health. The state’s Ministry of Health then compiles this data and sends it to the federal government. The federal government uses this data to make decisions regarding funding and hospital personnel. However, little is known regarding how physicians understand the production of data or how institutional requirements for data may affect their day-to-day work, particularly in the underfunded context of the public hospital. Another notable effect of Mexico’s health care reforms has been the increasing stratification of this system, resulting in profoundly different health experiences in public and private hospitals. The public health care system in Mexico is notably underfunded, as half of the health expenditure in Mexico remains within the private sector (OECD 2005:15). Furthermore, scholars note the poor infrastructure in many states in Mexico has created difficulties in effectively implementing Seguro Popular within hospitals in this region, observing issues like delays in transferring resources from the federal to the state level, misuse of funds at the state level, and challenges enrolling new beneficiaries (Gakidou, et al. 2006; Mills 2010). One important implication of the lack of funding and 22 ! ! infrastructure for the public hospital system is a notoriously poor quality of care for patients in public hospitals (Castro and Erviti 2003; Homedes and Ugalde 2009). Public health studies have repeatedly demonstrated a negative perception of public hospital services; results a 2006 survey showed that although a small minority of the population relies solely on private health institutions in Mexico, patients rated the quality of care and desire to return to private facilities much higher than public ones (Puig, et al. 2009). The expansion of the public hospital system without sufficient funding has profoundly impacted physicians working in the public hospital. Physicians in the public hospital system experience a large patient volume; some have estimated that public hospitals are regularly filled to two or three times their intended capacity (García 2015; Notimerica 2016). Additionally, physicians often lack the necessary equipment and supplies in public hospitals. Physicians at public hospitals receive notably low pay, resulting in a large number of physicians also working in the private sector to supplement their income (Molina and Palazuelos 2014). Researchers contend that such conditions contribute to a high rate of “burnout” among Mexican physicians (Toral-Villanueva, et al. 2009) Maternal health is particularly salient example through which the implications of Mexico’s changing health system can be examined. The insufficient funding of Mexico’s public health system is strikingly apparent in public maternity hospitals, as the number of women utilizing formal health care institutions has surged within the last several years due to concerted efforts of Mexican government to increase the number of women giving birth with a physician (Gutiérrez 2012:107; Langer, et al 2012). Additionally, maternal health in Mexico is an area in which the production of metrics is particularly significant. 23 ! ! Mexico remains under international scrutiny for maintaining one of the highest C-section rates in the world, as 45% of all deliveries are performed as a C-section (Suárez 2012). While the C-section rate has historically remained high in the setting of private hospitals, this number continues to increase in the public sector (Suárez 2012). However, it remains unknown why C-sections continue to rise in public hospitals and how physicians make decisions in public hospitals regarding delivery method. The following chapter will explore childbirth as a cultural system, particularly observing the effects of a neoliberal ideology in health care on the birth experience. Conclusion This chapter reviewed the defining features of the neoliberal agenda in health care, noting that utilizing a system based on profit and efficiency has fundamentally altered the health experience for patients and physicians. This system of health care is particularly disenfranchising for economically and socially marginalized groups, as they are unable to obtain quality care. Viewing the individual as personally responsible for his or her state of health, low-income groups are often blamed within health systems based on the neoliberal ideology for their poor health. Physicians are also impacted by the implementation of privatized health care systems, as financial interests come to dominate how care is administered, rather than physicians’ own knowledge. The increasing reliance of these health systems on metrics further limits physicians’ ability to make decisions, as physicians must work to fulfill particular measurements, rather than patient need. Institutional requirements, such as meeting certain metrics, structures the work physicians perform. Yet, further investigation is needed to examine how physicians understand these constraints and make decisions within this setting. 24 ! ! Mexico is a particularly appropriate location to explore this question, as the recent intensification of a system of stratified health care has resulted in profoundly different experiences between the private and public sector. Physicians in public hospitals are particularly subject to meeting institutional demands, as funding of public hospitals is in part based on how they perform. However, Mexican public hospitals are notoriously underfunded, serving a large number of patients without necessary resources. Thus, this dissertation aims to supplement current literature by examining how physicians in underfunded public hospitals understand institutional demands, and how these requirements shape physicians’ decisions. Childbirth is an appropriate example through which to examine such effects, as particular metrics like C-section rate and maternal mortality remain under scrutiny. The next chapter will introduce childbirth as a focus of anthropological study, as I discuss how childbirth can be utilized as a window through which the impact of political, social, and institutional context on physician decision-making can be further explored. ! ! 25 ! ! Chapter 2: Medical Decision-Making in Childbirth 26 ! ! Introduction The neoliberal agenda has profoundly impacted health systems, significantly altering the environments that physicians work within. Such changes are particularly visible in Mexico’s stratified health care system, as resource limited public hospitals increasingly contrast with the setting of private health care (Homedes and Ugalde 2009; Puig, et al. 2009). Furthermore, the emphasis on metrics revises institutional requirements within health care systems, resulting in a restructuring of physicians’ work environments (Adams 2016; Erikson 2012). In order to fully understand how physicians understand their options within the context of the public hospital, it is helpful to examine physicians’ decisions within a specific setting. This chapter introduces childbirth as a window through which the effects of such changes on physician decision-making can be understood. We must first explore childbirth as a unique cultural event before analyzing the effects of neoliberal policy on decision-making during birth. Childbirth is a particularly interesting setting in which to examine the influence of larger political, economic, and social structures on medical decision-making. Although childbirth is a universal physiologic process, the way in which it is practiced varies immensely cross-culturally (Jordan 1992). Physicians’ use of technology is a particularly variable aspect of childbirth, as use of technologic intervention like episiotomies, the use of forceps, epidurals, and C-sections vary widely (Davis-Floyd and Hollen 1994; Jordan 1992). C-sections are a particularly intriguing example of this variability, as C-sections have sharply risen in the last twenty years on a global scale (World Health Organization 2015b). This trend has been most visible in Latin America, where C-section rates have increased faster than any other region of the world (Suárez 2012). Mexico maintains one 27 ! ! of the highest C-section rates in Latin America and the fourth highest C-section rate in the world, with 45% of all live births delivered via C-section, providing a sharp contrast to the WHO’s recommendation of a national C-section rate between 10-15% (Gibbons, et al. 2012; World Health Organization 2015b; Suárez 2012). Similar to other countries in Latin America, Mexico’s C-section rate further varies by context; nearly 70% of births in private hospitals are C-sections, while public hospitals maintain a C-section rate of about 38% (Suárez 2012). Researchers have examined C-sections from physician and patient perspectives primarily within private institutions, asserting that cultural, social, and economic variables account for high rates (Almeida, et al. 2008; Behague 2002; McCallum 2005; Roberts 2012). However, restricting these examinations to the context of the private hospital neglects to consider important variables of public hospitals, such as class and race dynamics, financial constraints, lack of infrastructure, and the way that such factors shape physicians’ experience. Furthermore, as data regarding women’s health is used by state, federal, and international organizations, it is important to consider how the emphasis on particular metrics might impact the way in which physicians respond to institutional requirements. This chapter ultimately aims to provide the appropriate background for the central question of this study: How do larger social, cultural, political, and economic structures influence physicians’ delivery decision-making process at two public hospitals in Southern Mexico? Features of Medicalized Childbirth Childbirth marks a universal life event, yet the way in which it is practiced varies greatly depending on sociocultural and politico-economic context (Ginsburg and Rapp 28 ! ! 1991; Hollen 2003; Jordan 1992; Lazarus 1994). Brigitte Jordan (1992) writes that childbirth acts as a time of risk and transition; thus, a particular set of practices or rituals is necessary to manage this danger. Jordan observes that this perceived danger leads to practitioners of a particular culture to see their system as “the best way, the right way, indeed the only way to bring a child into the world” (1992:4). Jordan’s point is particularly salient in the practice of medicalized birth, as hospitalized births are widely established as the standard for childbirth in Western cultures, while other forms of delivery, such as the use of traditional birth attendants, are viewed as “alternative” (Davis Floyd and Davis 1996). Although in Western cultures hospital birth is often presumed to be the “correct” method for labor and delivery, medicalized childbirth is a relatively new practice. In the United States and Europe, childbirth transitioned from a “social birth” in the confines of women’s homes with a midwife to “scientific birth” in a hospital in the late 18th century (Leavitt 1983). The institutionalization of childbirth led to a profound paradigm shift in how birth was understood and performed in Western cultures; birth shifted from being viewed as a normal physiologic process to a risky and pathological state (Hahn 1987). As birth became conceptualized as dangerous, the obstetrician increasingly acted as the center of the medical encounter, viewed as integral to controlling and intervening in the birth process (Barker 1998; Oakley 1984). Within this type of practice, physicians occupy a key position during childbirth, as they possess knowledge not accessible to the lay public, interpreting the signs and symptoms of a patient (Davis-Floyd and Hollen 1994). This knowledge enables the physician to take on a central role in decision making, creating an unequal dynamic between physician and patient (Gamlin 2013; Jordan 1997). 29 ! ! Social, Cultural, and Economic Agency and Decision Making during Childbirth While decision-making should ideally be a shared process between physician and patient, the physician’s access to medical knowledge results in the physician occupying a position of greater authority than patients (Davis Floyd and Davis 1996). Jordan refers to this discrepancy as “authoritative knowledge,” noting that a particular system of knowing gains superiority above others, coming “to be perceived not as socially constructed, relative, and often coercive, but as natural, legitimate, and in the best interest of all parties” (1997: 57). Jordan emphasizes that the accuracy or correctness of this knowledge is not necessarily important, but rather the significance of this knowledge is that its powerful practitioners consider it to “count,” dismissing all other forms of knowledge. Birth within the setting of the hospital reinforces the hierarchical place of the physician, as they exclusively maintain access to such knowledge (Davis-Floyd 1987; Jordan 1997). However, given that the knowledge valued in a biomedical birth is medically based rather than intuitive or embodied, women of varying social, cultural, and economic positions have differential abilities to access this knowledge. Women of low social and economic standing are particularly constrained in obtaining this knowledge, thus amplifying the existing power discrepancy between physician and patient (Davis Floyd and Davis 1996; Fiedler 1996; Lazarus 1994). Additionally, structural factors like lack of access to nutritious food, clean water, prenatal supplements, and transportation to appointments subject these groups of women to blame in biomedical encounters (Gamlin and Hawkes 2014; Smith-Oka 2013b). Viewed as “high-risk” or irresponsible mothers, these women may be further restricted in their ability to participate in biomedical 30 ! ! decision-making (Hyatt 1999; Smith-Oka 2012b). The impact of social, economic, and cultural hierarchies on the power dynamic between physician and patient is particularly important to keep in mind when examining how the neoliberal ideology influence the childbirth experience. As neoliberal policy in Mexico has strengthened a system of stratified health care, the influence of socioeconomic variables on decision-making is particularly relevant in the public hospital system, where largely middle class physicians treat low-income women. Childbirth and the Neoliberal Agenda Some scholars contend that neoliberal systems of health have further restricted women’s ability to participate in decision-making during childbirth. One notable effect of privatizing health care is that childbirth has become an increasingly commercialized event in which women with more money are afforded more options. Women with greater social and financial agency maintain a greater number of choices for childbirth in terms of location, birth attendants, and technology (De Vries, et al. 2002; Lazarus 1994; Murray 2000). This is particularly illustrated in the natural birthing movement in the United State, where predominantly white middle and upper class women elect to utilize midwifes or give birth outside of the hospital system (Craven 2007; O'Connor 1993). Similar trends have emerged in Mexico, where birth with a traditional midwife is frowned upon by much of the medical community, but an increasing number of middle class women utilize Western trained midwives (Vega 2016). Women of low social, economic, and cultural standing are significantly more limited in their options during childbirth birth. As neoliberal reforms have swept across Latin America replacing formerly nationalized systems of health, low-income women 31 ! ! utilizing formal health services are left with the option of underfunded public hospitals and clinics. This trend is especially apparent in Mexico, as in recent years, as the Mexican government increasingly encouraged women to give birth in hospitalized settings (Langer, et al. 2012). These efforts are particularly visible in programs that target women’s health, such as Prospera, a conditional cash transfer (CCT) program created by the federal government. In this program, women are given small amounts of money for behaviors like attending clinic visits, receiving prenatal care, vaccinating their children, and giving birth in a hospital (PROSPERA 2016). A 2012 National Health Survey (Encueta Nacional de Salud y Nutrición) observed the effects of these efforts, as 29% of births took place in an SSA institution in 2006, while this number jumped to 43% in 2012 (ENSANUT 2012:107). Although a major motivation of the government focusing on increasing births in formal health care institutions in Mexico was to reduce maternal mortality, researchers noted that there was no direct correlation of this increase on maternal mortality rates (CONEVAL 2012a). Rather, scholars have detailed some strikingly negative implications of the increase in hospitalized births in Latin America. First, as noted in the previous chapter, the quality of services in public maternity hospitals has been observed to be notoriously poor, as public hospitals lack basic supplies and the capacity to manage a large number of patients (Ballinas 2009; Tamez González and Eibenschutz 2008). In addition to a shortage of resources, social scientists have observed that blatant humans rights abuses, typically against low-income women from rural areas, have occurred for decades in Latin American hospitals, naming forced sterilizations, verbal abuse, and suboptimal care as a handful of examples of such abuse (Castro and Erviti 2003; D'Gregorio 2010; Sadler, et 32 ! ! al. 2016). Terming such forms of abuse as “obstetric violence,” a number of countries in South and Central America, including Venezuela, Argentina, and Mexico have passed laws against such treatment (World Health Organization 2014). Yet, critics contend that such legislation remains largely ineffective, as the pathway for patients to press charges is undefined and what exactly constitutes obstetric violence remains unclear (Dixon 2014; Majety and Bejugam 2016). Scholars continue to observe the presence of discrimination in the public hospital setting, noting that existing social, political, and economic hierarchies are continually reproduced in this setting (Gamlin and Hawkes 2014; SmithOka 2015). This is particularly visible in examining the breakdown of maternal mortality in Mexico; the maternal mortality rate of indigenous women in Mexico remains three times higher than the rest of the population in Mexico (CDI 2010). Neoliberal health policies have resulted in magnifying disparities in the health care setting, limiting low-income women to services in underfunded public maternity hospitals. The inherent power division between physician and patient is amplified when women possess little social, economic, and cultural agency (Gamlin and Hawkes 2014; Lazarus 1994). Thus, it is critical to consider this power dynamic in examining medical decision-making within a specific setting, such as a public Mexican hospital, in which middle class physicians treat rural and indigenous women. The next section of this chapter will explore how the use of technology may reflect the effect of such variables on decision-making. Challenging Physician Neutrality: Decision-Making and Technology The use of technology provides a salient window through which to examine the social and cultural dynamics that underlie the decision-making process, as interventions 33 ! ! such as use of forceps, episiotomies, epidurals, the administration of oxytocin, and Csections differ immensely depending on the setting. The wide variation in how technology is utilized suggests that social, cultural, and political context is critical to how the decision to apply technology is made. C-sections especially illustrate this variability, as in addition to widely differing rates of C-sections between countries; researchers have observed strikingly different C-section rates between different contexts in the same region (Hopkins 2000; Roberts 2012; Suárez 2012). Scholars have observed this trend in Latin America for years, as C-section rates in private hospitals are nearly triple the rate of public hospitals (Barros, et al. 2011; Suárez 2012). Examining the varying C-section rate between public and private hospitals begets questions of social, cultural, and economic dynamics, as women utilizing the private hospital service are exclusively middle or upper class. Researchers examining decisionmaking regarding C-sections have been largely considered from the perspectives of women and physicians in the private hospital system. Studies exploring the viewpoints of women in the private hospital sector have suggested that women pursue C-sections for a variety of motivations, including aesthetic reasons, avoidance of pain, a desire for sterilization with a C-section, and a way to avoid the perceived indignities of the public hospital system (Barros, et al. 1991; Béhague, et al. 2002; McCallum 2005; Quadros 2000). Other researchers have turned their focus towards physicians’ perspectives on delivery method, challenging the assumption that C-sections are primarily performed due to women’s demand. Klimpel and Whiteson (2016) assert that examining how physicians conceptualize the desires of their patients is critical to understanding how 34 ! ! physicians present options to patients, finding that physicians’ belief that women want Csections leads them to present C-sections in a more favorable light, as they assume that higher class women utilizing private services must want a C-section (Klimpel and Whitson 2016). Additional studies have suggested alternative motivations for physicians to perform C-sections. Hopkins (2000) contends that the majority of women she interviewed in a private Brazilian hospital actually wanted a vaginal birth, but ended up having a C-section. In examining interactions between physicians and patients, she noted that physicians frequently presented C-sections as the preferable and safest option. Hopkins explores various motivations behind physicians’ preference for a C-section, observing increased financial compensation for C-sections over vaginal birth and greater convenience for physicians with scheduling C-sections. Other studies have observed that the particular culture of an institution remains influential in physician’s decisions. For instance, several studies noted that physicians working in hospitals with particularly high rates of lawsuits were more likely to perform C-sections in the absence of clear-cut indications, due to the fear of being sued (Bassett, et al. 2000; Localio, et al. 1993; Tussing and Wojtowycz 1997). However, factors such as physicians’ impressions of wealthy patients, financial motivation, convenience, and legal concerns are primarily restricted to the private hospital. These dynamics may be profoundly altered in the setting of the public hospital. Yet, little is known regarding how physicians in the public hospital setting make decisions regarding use of technology, particularly in regards to delivery method. Mexico provides an opportunity to examine this question, as C-section rates in the public hospital 35 ! ! sector continue to increase each year (Suárez 2012). Next, I highlight critical considerations for exploring decision-making in the setting of the public hospital system. Physician Decision-Making in the Public Hospital System Many of the previous studies that examined patient and provider perspectives on delivery method decision-making in Mexico have been performed in the context of private health care institutions with the highest C-section rates. However, restricting the examination of such decisions to the context of the private hospital neglects key dynamics unique to the public hospital system. As discussed in Chapter 1, public hospital systems are often substantially underfunded and under resourced in comparison to private health care institutions. Social scientists contend that it is critical to consider how this context impacts physicians’ understanding of their environment and how they navigate through these constraints (Baer, et al. 2003; Singer 1986). For example, in Clare Wendland’s (2012) examination Malawian medical students, she found that young physicians navigated the rampant poverty that they encountered by developing a “moral map,” a perspective of their environment that creatively influenced their management of patients. Wendland found that students developed greater physical exam skills in the absence of technology and largely blamed structural problems for patients’ health disparities, rather than the patients themselves. However, other researchers have observed strikingly negative implications of the lack of resources and funding on physician decision-making. Diniz and Chacam (2004) provide an example of this in their study of birth technology in Brazil. Noting that the underfunded Brazilian hospital system lacked basic supplies, like a sufficient number of hospital beds, the authors found that physicians were more likely to perform 36 ! ! unnecessary episiotomies without pain medication on patients in public hospitals to speed up the birth process. In addition to the impact of financial limitations on physicians in the public health system, scholars note that social dynamics between physicians and patients in public hospital vary from those in the private setting, as primarily middle class physicians treat low-income patients. Mexico provides a particularly appropriate location through which to examine such power divides, given its history of complex race and class relations. Previous studies have noted the varying treatment of patients in public hospitals, as compared to private hospitals. For example, Castro found that low-income women in public Mexican hospitals are three times more likely than women in private hospitals to be sterilized during a C-section delivery (2004: 138). Castro notes that physicians primarily utilize the risk of uterine rupture in their rationalizations of this practice, yet Castro also observes that physicians’ personal opinion that two or three children constitute the “ideal number of children” also arose in these conversations (2004:138). Finally, the institutional requirements of public health settings vary from those of private hospitals. As discussed in Chapter 1, public hospitals in Mexico are subject to assessment from both the state and national government that primarily rely on data produced from each hospital regarding particular outcomes. It is also important to consider how this data might be used on an international scale, as maternal health has become a focus on global health agencies. A number of studies have observed that the pressure to obtain “good” outcomes, such as a low maternal and infant mortality rate, shapes the way in which data is produced (Oni-Orisan 2016; Wendland 2016). Such concerns are particularly relevant in Mexico, as Mexico is currently under international 37 ! ! scrutiny for failing to achieve the Millennial Development Goal for maternal mortality (Victora, et al. 2015). As public hospitals have historically possessed the highest rates of maternal mortality, public institutions are particularly subject to scrutiny for this measurement (Freyermuth 2014:63). The impact of fulfilling such metrics is beginning to surface in Mexico, as Williams (2016) suggested that physicians might disregard unfavorable data, such as complications that arose during birth, to produce “better” numbers, such as a lower number of obstetric related complications. Conclusion Current literature lacks an examination of how physicians understand the requirements of their institution, particularly in a setting of limited resources. How might physicians’ perception of institutional requirements impact their decisions in labor and delivery? How do physicians navigate these requirements in the resource limited setting of the public hospital? How do physicians conceptualize patients who are socially and economically marginalized? How might such understandings influence physicians’ decisions? How might the institutional requirements of the public hospital system perpetuate existing social, economic, and political hierarchies? This dissertation aims to address these questions through examining physicians’ decision-making process for delivery method at two public hospitals in the Yucatan, Mexico. In order to explore these questions, it is critical to situate this study amidst the background provided in Chapters 1 and 2. While Chapter 1 examined of the impact of the neoliberal ideology in health systems on patients and providers, this chapter introduced childbirth as a culturally specific event, varying widely in how it is practiced. Within a system of medicalized childbirth, patients’ limited social and economic resources amplify 38 ! ! the inherent power divide between physician and patient during childbirth. This power differential is exacerbated in public hospitals, a setting where middle class physicians treat low-income patients. Mexico provides an intriguing setting to examine this dynamic, as thousands more patients have been funneled into the underfunded Mexican public hospital system in the last several years. An implication of increasing hospitalized births in Mexican public hospitals has been the presence of discrimination and abuse towards marginalized groups (Castro and Erviti 2015; Smith-Oka 2012a). The use of technology is a particularly interesting window through which to explore how physicians’ perceptions of these groups, as studies have observed that varying standards for using technology have been applied to different groups (Castro and Singer 2004; Diniz and Chacham 2004). C-sections are an intriguing example to study the factors that influence physician decision-making, as C-section rates have historically varied between public and private institutions. As C-sections continue to increase in public Mexican hospitals, this dissertation will explore how the context of the public hospital, along with Mexico’s history of race and class based discrimination, shapes physicians’ decision making regarding delivery method. The next chapter further explores why the state of the Yucatan was an appropriate location for this project, focusing on the work environment for physicians at these hospitals. ! ! ! ! ! 39 ! ! ! ! ! ! ! ! Chapter 3: Settings and Methods 40 ! ! Settings Introduction Mexico’s stratified system of health care has resulted in significantly different experiences for patients and providers in public and private hospitals. Childbirth is a particularly salient example through which to examine the effects of social, political, and economic factors on physician decision-making, as the way in which childbirth is performed in the public and private context varies immensely. This is evident in examining C-section rates between the private and public settings, as approximately 70% of births are delivered via C-section in private hospitals and 38% of deliveries are Csection rates in public hospitals (Suárez 2012). While research has suggested that reasons such as financial incentive, convenience, and patient demand influence physicians’ decisions for C-sections in private hospitals, further investigation is needed to examine how physicians elect to utilize C-sections in public hospitals. The state of the Yucatan is a particularly fitting location to carry out this research, as the Yucatan maintains one of the highest C-section rates in Mexico, with 40-57.5% of all deliveries in 2012 occurring as C-sections (Suárez 2012). Maternity hospitals in the state of the Yucatan have remained notably affected by changes to Mexico’s health care policy, as the number of women giving birth in the setting of a hospital has surged within the last decade (Freyermuth, et al 2014). Given that increase was largely seen among low-income women, the public hospital system in the Yucatan has been especially affected by such policies. Yet in order to understand how this shift might shape the decisions of physicians working in the public hospital system, it is critical to consider these changes amidst the Yucatan’s history of complex race and class relations. This 41 ! ! chapter will introduce the city of Merida and the state of the Yucatan, focusing on historical events that have influenced the current sociocultural dynamic of this region. A Demographic Overview of Yucatan, Mexico The early history of the Yucatan peninsula mirrors that of other countries in the Americas. Beginning with the Spanish Conquest of the Americas in the 15th century, Spanish invaders utilized indigenous groups as slave labor for building their new empire. The abuse of indigenous groups persisted after Mexico’s independence from Spain, as wealthy landowners utilized indigenous groups as inexpensive labor sources (Rugeley 2010; Wade 2008). Discrimination against indigenous groups is strikingly apparent in the Yucatan Peninsula, a region of Mexico with a large number of Mayan inhabitants. While the Yucatan Peninsula maintains a somewhat distinct social and political history from the rest of Mexico due to its relative geographic isolation, similar to other parts of Mexico, indigenous groups were socially, politically, and economically marginalized for centuries. Twenty years after Mexico’s independence from Spain, in 1841, the Yucatan Peninsula separated from the Mexican nation, forming its own state (Dumond 1997). While the Yucatan rejoined Mexico in 1843, a unique history in the Yucatan continued to unfold. A particularly notable time in the Yucatan’s history is the Caste Wars of 1848. One of the bloodiest moments in the history of the Yucatan, the Caste War of 1848 highlighted underlying social tensions between the rich, landowning Spanish descendants (creoles) and the indigenous, landless classes. Laws restricting landownership and high tax demands on indigenous groups amplified underlying strains, culminating in war 42 ! ! (Reed 1964). While a peace treaty was officially signed in 1855, scholars note lasting effects of the Caste War on marginalized groups. Wolfgang Gabbert (2001) contends that although not all individuals fighting against the Yucatan government in the Caste War were of Mayan decent, this event deepened discrimination against inhabitants of Mayan decent. For example, he notes documents that refer to individuals of Mayan decent as “savages” or “barbarous Indians” (2001: 471). Some scholars assert that in addition to the wealthier, landowning class’ negative view of indigenous individuals, documents from this time period suggest that indigenous groups’ view of themselves shifted as well. Shannon Mattiace (2009) posits that the Caste War “created a process of de-Indianization in the Yucatan: Mayans effectively dissociated themselves with any Indianness” (2009:141). She notes that few Mayan individuals referred to themselves as indigenous or Indian after the Caste War, given the negative connotations with such terms held by citizens of higher social classes (2009:143). In addition to social discrimination, scholars observe that indigenous Mayan groups also remained economically marginalized, working primarily as cheap labor sources in the boom and bust cycles of products like henequen during the 19th and 20th centuries (Joseph 1985; Wells 1992) Scholars note that discrimination against indigenous groups continued in 20th century. To understand the interplay of race and class within the Yucatan, it is important to observe the broader social dynamics of Mexico during this time. Particularly after the Mexican Revolution ended in 1920, historians observe that the concept of the “mestizo” became a key tenant of nation building identity. Viewing “mestizo” as a form of hybridity, Loewe (2010) writes that Latin American intellects in the 20th century 43 ! ! understood the concept of the mestizo as a blend of cultural, social, and racial characteristics between the Spanish and indigenous groups of Latin America. Loewe posits that these scholars felt that through promoting Mexico as mixed, this mestizo identity would unite the nation and propel it towards progress (2010:4). Yet, as Alan Knight (1990) points out, priding the mestizo as a modern, national representation provided juxtaposition to indigeneity, relegating indigeneity as a symbol of a pre-historic, backwards way of being (1990:71-73). Batalla and Dennis (1996) powerfully emphasizes this point, contending that Mexico profundo, the authentic, indigenous expression of Mexican character, remains obfuscated by Mexico imaginerio, a Western ideal of progress and civilization. Gabbert (2001) notes that the larger prejudice against indigenous individuals in Mexico was present in the Yucatan, yet often was expressed in subtle interactions, such as characterizing those that spoke Mayan or dressed in a particular way as simple and uneducated. The effect of centuries of colonization and disenfranchisement of indigenous groups is evident in present day Yucatan, as striking educational, financial, and health disparities persist between indigenous groups and the rest of the state. The state of the Yucatan contains the second highest number of indigenous language speakers in Mexico, with over 29% of individuals over three years old speaking an indigenous language (INEGI 2015:61-62). Yet, the majority of indigenous speakers live in rural areas, as less than 75,000 individuals out of the nearly 830,700 residents in Merida speak an indigenous language (CONEVAL and SEDESOL 2015:1). Few studies directly compare social, educational, and health measures of indigenous groups to non-indigenous groups in the Yucatan, however, examining the breakdown of such assessments by rural and 44 ! ! urban locations can be illuminating. While in 2010, 38% of the state of the Yucatan was estimated to live in moderate poverty, the state’s most rural areas maintained levels of poverty as high as 90% (CONEVAL 2012b). Studies in rural areas consistently demonstrate higher rates of malnutrition, fewer years of education, and lower household income than in urban areas (CONEVAL 2012b; Leatherman and Goodman 2005). The poverty in rural areas of the Yucatan contrasts sharply with the urban setting of Merida. Merida contains roughly 830,700 of the Yucatan’s nearly 2 million residents, and holds the overwhelming majority of the Yucatan’s schools, universities, and hospitals (INEGI 2010). Three medical schools are located in the heart of Merida, in addition to all of the third tier hospitals (the hospitals with the greatest resources for care) and most of the second tier hospitals. Thus, when women living in rural areas seek to deliver in a hospital, they must travel to one of these hospitals in Merida where middle-class physicians treat them. As discussed in Chapter 2, larger social, economic, and political hierarchies importantly shape physician-patient interactions in the clinical setting, particularly in childbirth, where an already inherent power divide exists between physician and patient. Individuals with few social, economic, and political resources may become further marginalized within the setting of health care, possessing limited agency in the decisionmaking process (Gamlin 2013; Lazarus 1994). Furthermore, larger social discrimination, combined with the stressful, underfunded public hospital system may additionally result in poor treatment of particular groups in the clinical setting (Smith-Oka 2015). The urban and rural divide in the Yucatan, influenced by years of cultural and economic marginalization of indigenous groups, is critical to consider in examining how physicians 45 ! ! conceptualize patients in public maternity hospitals. How does sociocultural and political-economic status influence physicians’ characterization of this patient population? How does this understanding shape interactions in the context of the public hospital? How do physicians’ views of patients influence their decision-making process? Maternal Health in the Yucatan Childbirth provides a window through which broader social, racial, and political inequalities in the Yucatan can be examined. The system of childbirth in the Yucatan has undergone a profound shift in the last several decades, moving from a system of midwifery to hospitalized births. Midwifery has a deep history in Mexico, as the use of midwives has been recorded as early as the pre-Hispanic era (Trueba 1994). Anthropologists have extensively studied births with midwives in Mexico, as techniques and rituals utilized during these births have been documented (Carrillo 1999; Cosminsky 2001; Jordan 1992; Robles and Sandoval 2007). While the specifics of births with midwives vary by region in Mexico, births with midwives generally occur in a women’s home or community. In her study of midwifery in Mexico, Brigitte Jordan (1993) writes that a laboring woman and midwife hold equal power during childbirth, as they make decisions together regarding when to eat, when to push, and how to push (87). However, in recent years, the Mexican government has required these midwives, referred to as “traditional birth attendants” (TBA), to attend classes in attempts to integrate modern obstetrics into their practice (Jordan 1989). Roslyn Vega (2016) points out that the use of TBAs in Mexico is highly stigmatized, and is primarily utilized by low-income, indigenous women. 46 ! ! Rather than the use of TBAs, Mexico’s government has strongly encouraged women to give birth in formal health care institutions in recent years. As discussed in Chapter 2, a driving factor behind the Mexican government’s push to increase hospitalized births was the assumption that physician attended births would result in a low maternal mortality rate (MMR) (Hogan, et al. 2010). As rural, low-income, and indigenous groups possess the highest rates of maternal mortality, the Mexican government designed policies that particularly focused on changing the behavior of these individuals (CDI 2010). One policy through which the Mexican government attempted to increase hospitalized births was the implementation of Conditional Cash Transfer (CCT) programs, such as Prospera (formerly Oportunidades). In such programs, low-income women are given cash stipends for performing particular behaviors, including seeking pre-natal care and giving birth with a physician in a formal health care facility (PROSPERA 2016: 56, 62). These policies have drastically altered the way that childbirth is performed in the Yucatan. While 63.6% of births occurred with a skilled health attendant in the Yucatan in 1990, by 2014, that number increased to 94.9% (Freyermuth 2014). As the WHO defines “skilled health attendants” as biomedically trained physicians or nurses, TBAs are explicitly excluded (World Health Organization 2004). Thus, the increase in births with skilled health attendants indicates that the number of births that occurred within formal institutions, such as hospitals and community clinics, sharply rose. This dramatic shift in birth setting and participants begets the question of how the experience of giving birth has transformed. As Chapter 2 detailed, one implication of increasing hospitalized birth has been the abuse and discrimination encountered by 47 ! ! marginalized women seeking services in public maternity hospitals (Castro and Erviti 2003). Another important consideration in examining the effect of the change in birth setting is the way in which technology is applied during birth. C-sections are a particularly intriguing example to explore this change, as C-sections continue to increase in public Mexican hospitals. Some scholars contend that the increase in hospitalized births is directly correlated with the increase in C-sections. For example, Sarah Barber (2010) found that beneficiaries of Prospera receiving services in public hospitals were more likely to receive a C-section. Barber speculates that this increase in C-sections could be due to an increase in women’s disposable income from their conditional cash stipends. However, Barber does not interview any women in her study, and neglects to consider how physician perspective influences the type of delivery. Thus, while a number of scholars have observed the rising number of C-sections in public health care institutions, it remains poorly understood what factors contribute to this increase. Public hospitals in the state of the Yucatan are a particularly appropriate setting to examine the dynamics of decision-making, as the Yucatan maintains one of the highest C-section rates in Mexico. A 2012 study estimated that between 40- 57.5% of all live births are performed via C-section in the Yucatan state (Suárez 2012). This number is a marked increase from 2006, in which 35-39% of births were delivered by C-sections (Suárez 2012). This staggering rise in C-sections contributed to my decision to utilize two public hospitals in Merida as my research sites. Examining this phenomenon amidst the backdrop of profound race and class discrimination in Mexico, this study seeks to explore the political, social, and economic factors that shape physician decisions for delivery method at two public hospitals in the Yucatan. 48 ! ! Medical Training in Mexico As this study considers decision-making regarding delivery method from physicians’ perspectives, it is critical to provide a brief background on the system of medical training in Mexico before examining how physicians elect for particular options. Medical school in Mexico is six years, followed by several years of residency training. Students take an entry exam while in high school, and accepted applicants begin medical school after high school. While the first several years of medical school are generally spent in the classroom studying basic sciences, the last several years of medical school focus heavily on clinical experience. Students’ fifth year of medical school is referred to as their “intern year” and is almost entirely clinical. Students rotate throughout medical services like pediatrics, general surgery, obstetrics and gynecology, emergency medicine, and anesthesia for approximately one month at a time. Interns work the same schedule as residents, with a normal workday lasting between 8-10 hours and a 34-hour overnight shift every three days. Students’ final year in medical school is referred to as their service year (el año de servicio). Students are assigned to a community health center, often in rural areas of the state, and work as the physician in this clinic for a year. I decided not to recruit interns for interviews in this study for several reasons. First, interns only rotate on obstetrics and gynecology for a few weeks. I felt that this would be an insufficient amount of time for interns to gain a perspective on the decision making process. Additionally, interns rarely are involved in the decision-making process for delivery method, as they primarily perform tasks like taking vitals, handing instruments to residents during surgeries, and taking blood samples from patients. Finally, given their position as rotating medical students, I felt that they would not be 49 ! ! subject to the same institutional pressures as residents, who are training for careers as obstetricians and gynecologists. However, several interns signed consent forms for participant observation and are included in my observations. Although I did not conduct interviews with interns, they were a valuable source of knowledge on the logistics of the labor and delivery ward. In students’ final year of medical school, they can take the National Residency Exam (ENARM) if they plan to pursue a residency. The residency placement process is extremely competitive, as few spots exist for a large number of applicants. For example, in 2012, approximately 28,000 students took the exam, and less than 7,000 obtained a residency spot (CIFRHS 2012:8). Students often retake the exam the following year and reapply if they do not match. If students elect to not perform a residency, they are still able to work as a general practitioner in Mexico. Training in obstetrics and gynecology is a four-year residency in Mexico. Residents rotate throughout a variety of services during their training, such as obstetrics, gynecology, gynecologic oncology, and maternal fetal medicine. Residency is a grueling process in Mexico; residents regularly work over 90 hours a week with an overnight shift every three nights. Additionally, scholars have noted the system of medical hierarchy to be particularly harsh during residency; reports of senior physicians hazing residents and medical students by extending their hours or demanding that they perform additional tasks are not uncommon (Casas Patiño 2013). Researchers have observed “burnout” syndrome to be particularly common among medical residents, along with high rates of depression and suicide (Suñer-Soler, et al. 2014; Toral-Villanueva, et al. 2009). 50 ! ! The stress endured by Mexican physicians was a particularly noteworthy topic during my first summer of fieldwork in 2014. In 2014, a judge in Jalisco found 16 physicians to be guilty of negligence and manslaughter over the death of a 15-year-old boy in an IMSS hospital in 2010. This verdict sparked outrage among other physicians, as physicians pointed out that many of the doctors involved in this case had worked over 100 hours weeks during the time this patient was admitted to the hospital (Villaseñor, Thamara, “Confirman negligencia de IMSS Jalisco, dictan prisión a 16 médicos”, El Informador, June 4, 2014). Shortly after this verdict, protests arose across the country, featuring the twitter hashtag “#YoSoy17” (I am number 17), referring to the 16 physicians who had been convicted, implying that any of physician could have been the potential 17th physician involved in the case. Signs carried by protesters in these marches read messages such as “We are physicians. We are not gods. Nor are we criminals” (Morales, Yolanda “#YoSoy17, no somos dioses, somos médicos,” El Economista, June 20, 2014). While no policy changes in physicians’ work hours resulted from this movement, the widespread outrage among physicians over this verdict drew attention to the brutalizing work environment in which the physicians practice. Given the rigid system of medical hierarchy and grueling hours for residents, I wanted to examine how this stress might influence their decisions. Additionally, I was interested in the interactions between senior physicians and residents, particularly in how residents were socialized to make the “correct” decision regarding delivery method and the repercussions for decisions deemed to be in poor judgment. Finally, I wanted to explore how residents learned the process of decision-making in the resource poor environment of public maternity hospitals. 51 ! ! Site Locations As the recent increase in hospitalized births has primarily affected low-income women utilizing public hospital services, I wanted to focus on the public hospital environment for this project. Merida is the ideal site to capture this dynamic, as all the third tier hospitals (hospitals with the greatest number of services) and the majority of the second tier hospitals (hospitals with more limited services) in the Yucatan are located in Merida. I carried out my research at two public hospitals in Merida with a shared OB/GYN residency program, Hospital General and Hospital Pequeño. Hospital General is a third-tier hospital, while Hospital Pequeño is a second-tier hospital. Thirty-two OB/GYN residents complete their four years of residency between the two hospitals. I spent most of my time in each hospital in the labor and delivery ward, as I found the decision-making process to be most visible in the intense environment of labor and delivery. I occupied a unique position, due to my role as both a medical student and researcher. While I introduced myself as a dual medical student and graduate student who was there as an Anthropology student performing a project regarding physician decision making, the physicians in both locations primarily treated me as a medical student. Initially, physicians were eager to try to demonstrate to me the amount of clinical experience I could gain while being there. Upon arrival in May 2014, one Englishspeaking resident remarked to me, “The last American student we had here rotating here was performing all of the C-sections by the end of her rotation. You can’t get experience like this in the United States.” I was required by both hospitals to wear scrubs in the labor and delivery unit, compounding confusion that I was a rotating medical student. Physicians frequently asked if I wanted to delivery babies, scrub in on surgeries, or 52 ! ! perform vaginal exams. I was careful to refuse such requests and reaffirm my position as a researcher. I noticed a change in my second field season at both sites, as the physicians I had met during the previous summer acknowledged my role as a researcher and I received fewer invitations to perform medical procedures. However, I recognize that my dual status as a medical student and researcher influenced my position in the hospital. I felt that physicians may have been more open to me observing them in their day-to-day activities, knowing that I was familiar with conditions and procedures that they discussed. (i.) Hospital General Hospital General is a large, public hospital in Merida. In my pilot work, many of the physicians at Hospital General expressed that they feel it is the most technologically advanced public hospital in the region and a preferred location to train for residency due to the large number of patients seeking treatment at this hospital. The maternity ward of Hospital General is attached to the general hospital, thus when complications arise, clinicians are able to refer patients to other departments, such as the neonatal intensive care unit. Due to the greater availability of resources at Hospital General, a larger number of complicated births are referred to this hospital. The higher proportion of complicated births is reflected in the C-section rate of this hospital, as 2014 statistics from Hospital General estimate that approximately 55% of births are C-sections, in comparison to Mexico’s national C-section rate of 45% (Suárez 2012). Residents at Hospital General must rotate through several services during their four years of residency, including the labor and delivery ward, the post-partum ward, oncology, an outpatient procedure clinic, and two months in Hospital Pequeño. Regardless of the service that residents work on, they maintain the same hours throughout 53 ! ! the first three years of residency. Besides one free day a week, residents work 10 hours a day, with a 34-hour shift every third day. For example, a resident might enter at 6 AM on Monday, work the guardia (overnight shift), and leave at 4 PM on Tuesday. The resident would arrive at 6 AM on Wednesday and leave at 4 PM on Wednesday. This resident would work another guardia on Thursday, arriving at 6 AM and leaving at 4 PM Friday. The resident would work until noon on Saturday, and have Sunday free. Fourth year residents have one less guardia per week, as they perform this overnight shift every 4 days. All other residents regularly average 100 hours of work per week. Senior physicians typically work eight-hour shifts. There are three shifts per day: a morning shift, an afternoon shift, and an overnight shift. Nearly all of the senior physicians at both Hospital General and Hospital Pequeño work at a private hospital or ISSSTE after their shift at Hospital General or Hospital Pequeño. The roles and responsibilities for residents and interns are highly structured at Hospital General, based on year of training. For example, first and second year residents typically perform pre and postnatal examinations and deliver vaginal births. Third and fourth year residents perform both vaginal births and C-sections and supervise the first and second year residents. Senior physicians reported that their role is to supervise residents of all levels, and manage the most complicated births. However, in my observations, I found that senior physicians’ roles may serve a more bureaucratic function, as during many shifts, senior physicians can be found socializing and sharing YouTube videos in their break area. Medical hierarchy is so firmly established in this hospital that physical spaces are arranged according to training level, as interns, residents, and senior physicians utilize different spaces within the birthing ward to document 54 ! ! patient charts and to take breaks. The interns’ room, termed pecera (fishbowl) due to windows on three sides, is especially representative of this rigid training structure, as residents often tap on these windows to make requests of the interns or to expedite their work. (ii.) Hospital Pequeño Each resident must also complete a two-month rotation at the smaller, secondlevel Hospital Pequeño during his or her second year of residency. Hospital Pequeño is located several miles from Hospital General, in the heart of downtown Merida. Considerable bustle surrounds Hospital Pequeño; vendors line the streets outside of Hospital Pequeño selling products from sodas and tamales to DVDs. A bus station is across the street from Hospital Pequeño; physicians at Hospital Pequeño told me that women from rural areas utilize these buses to arrive at the hospital if they are able to afford it. Hospital Pequeño is significantly smaller in size than Hospital General, yet more births occur in Hospital Pequeño, as their sole service is obstetrics and gynecology. Physicians at Hospital Pequeño describe this hospital as a location intended for primarily low risk births. However, the C-section rate at Hospital Pequeño still remains above the national average of C-sections in public Mexican hospitals of 38%, as statistics given by Hospital Pequeño in 2014 approximate that 41% of the births that occur are C-sections. When complications arise, women are transported to Hospital General, due to greater medical resources. At any time, approximately eight interns, two residents, and one senior physicians physician work in the delivery ward of Hospital Pequeño. Interns rotate through various areas of the hospital, including pre-natal checks and caring for post- 55 ! ! partum patients. However, residents solely work in the labor and delivery ward during their rotation at Hospital Pequeño. Residents and senior physicians’ schedules at Hospital Pequeño are nearly identical to those in Hospital General. Residents work 10 hour days and a 34-hour shift every third night, and have one day off each week. Senior physicians work eight-hour shifts either in the morning, late afternoon, or overnight. Interns and senior physicians rotate through five different services at Hospital Pequeño, including labor and delivery, the operating room (OR), the post partum recovery area (termed el piso), regular prenatal checkups for women after 35 weeks (referred to as consulta), and exams for women past 35 weeks experiencing atypical pain (termed valoraciones). Second year residents exclusively rotated in labor and delivery or the OR. In Hospital Pequeño, physicians’ responsibilities slightly diverge from Hospital General due to the smaller number of physicians working. Interns and residents are generally given greater responsibilities than Hospital General. In consulta and valoraciones, interns typically help take patient history, measure women’s pregnant bellies, listen to the fetal heartbeat, and perform a vaginal exam (un tacto). Senior physicians supervise interns during this process, and usually perform an additional vaginal exam. The post-partum area is relatively slow paced. Interns primarily monitor patients, checking their vital signs, and incisions from a C-section every few hours. Senior physicians round with interns in the post-partum area once in the morning and once in the afternoon. In labor and delivery, interns are responsible for monitoring patients in labor and for performing vaginal deliveries, supervised by a second year resident. While only third and fourth year residents perform C-sections at Hospital 56 ! ! General, second year residents perform C-sections in Hospital Pequeño under the direction of senior physicians. Interns, residents, and senior physicians frequently remarked to me during my pilot work that they felt this smaller environment fostered better learning and camaraderie. Physicians of all levels share a break area in Hospital Pequeño, often ordering food or telling jokes during down moments. These hospitals provide an appropriate setting to examine this research question. While both hospitals serve a similar patient population and are located miles apart, the resources, roles and responsibilities of the resident physicians and senior physicians vary. I was particularly interested in utilizing Hospital Pequeño as a contrast to Hospital General, as I wanted to ensure that Hospital General’s high C-section rate was not solely due to receiving more complicated births. As Hospital Pequeño supposedly only accepts low risk births yet still maintains a high number of C-sections, I felt that by comparing both hospitals, I would gain greater insight as to how context, training structure, and institutional dynamics may influence physician decision-making during birth. Methods As I wanted to capture the multidimensional and interconnected factors that influence physician decision-making regarding delivery method, I utilized primarily qualitative methods in this study. I received IRB approval for this study in the spring of 2014 and received IRB renewal for this project in the spring of 2015 and 2016. In the summers of 2014 and 2015, I primarily piloted IRB approved questions to physicians at both of these hospitals and shadowed physicians. Through piloting questions with physicians, I wanted to understand their opinions of the hospital environment and the issues that they face. Throughout these three field seasons, I spent 108 hours observing in 57 ! ! Hospital General and 58 hours observing in Hospital Pequeño to understand the work dynamics of both settings, and to contrast these observations with piloted interview questions. I primarily shadowed physicians in the labor and delivery ward, but also spent substantial time in pre and post-natal consultations. Participant Observation I typically observed physicians for about 6-7 hours each day. I performed one guardia, or overnight shift, at each hospital. Prior to the observational stage of my project, the director of the OB/GYN unit informed all physicians in the OB/GYN unit that I would be shadowing for several weeks. Before shadowing any physician, I introduced myself, explained the aims of my project, and obtained written consent. Additionally, before observing a physician’s encounter with a patient, I introduced myself to the patient, gave a brief summary of my project, and obtained oral consent following an IRB approved script. None of the patients or physicians declined to participate. I ensured that with each introduction I clarified that I was not acting as a medical student, but rather as an anthropology graduate student conducting research. I handwrote my observations each day, and typed them up in a word document each night. I recorded the date, location, and beginning and end time of each observation in my field notes. I wrote down the training level of the physician that I shadowed (year of residency or senior physician) and gender. I also recorded basic patient characteristics, such as gestational age, age of the patient, and any relevant pre-existing conditions. During my observations, I sought to explore how institutional context, physicians’ place within this system, and their perception of patients may shape their decisions. For example, in attempting to understand how institutional structure might influence 58 ! ! physicians’ work environments, I examined: How do physicians manage high patient volume? How are physicians evaluated? How do physicians perceive the evaluation process? To investigate how medical hierarchy might play a role in decision-making, I observed: How do residents present information to senior physicians? How do senior physicians respond to this information? How do senior physicians reinforce or reprimand the actions of residents? Who ultimately makes the decision for a C-section? Finally, to better comprehend how physicians consider patient characteristics in their decision making process, I examined: What factors are most important in determining if a Csection should be performed? How do physicians describe patient characteristics in their decisions to pursue a C-section? How do physicians interact with patients with minimal education or Spanish language skills? Semi-structured Interviews After familiarizing myself with both locations and building relationships with physicians, I conducted semi-structured interviews during my third field season in Merida. I recruited physicians through convenience sampling, asking physicians if they would be interested in performing 30-60 minute interviews throughout my observations. Before each interview, each physician signed an IRB consent form. I also read a short paragraph to each physician before the interview, gave each physician an opportunity to ask questions, and informed each physician that he or she could decline to participate at any time. I interviewed 24 physicians in total, 17 residents and senior physicians from Hospital General and 4 senior physicians from Hospital Pequeño. I additionally interviewed the director of the OB/GYN Department at each hospital, and a physician who now works as a State public health official (see Table 1 for demographic information 59 ! ! for the physicians interviewed). All of the interviews except one were completed in Spanish. One interview was completed in English, as this physician expressed that he felt comfortable conducting the interview in English. Physicians in two other interviews switched to English for several sentences, but the rest of the interview was performed in Spanish. I aimed to interview physicians of varying training levels and backgrounds. At Hospital General, I was able to obtain interviews with physicians of all levels of training, except for third year residents. OB/GYN residents at Hospital General rotate in several different areas of obstetrics and gynecology, including Oncology, an outpatient procedure area, Hospital Pequeño, and the post-partum recovery floor. Many of the third year residents were rotating in other areas during my third field season. Additionally, the third year residents who are rotating in labor and delivery perform the majority of Csections, supervised by a fourth year resident. Since most of the third year residents were on other rotations or spent the majority of their time operating, I was unable to recruit any third year residents to this study. At Hospital Pequeño, I only interviewed senior physicians. Similar to Hospital General, senior physicians had the greatest availability to be interviewed. Additionally, as only two residents work at Hospital Pequeño at any time, the residents at Hospital Pequeño are incredibly busy. The residents rotating at Hospital Pequeño perform C-sections, track the progression of labor of patients in the labor and delivery ward, and supervise interns that deliver vaginal births. Therefore, it was difficult to find a 30-minute interval in which a resident was free for an interview. Senior physicians at Hospital General and Hospital Pequeño were eager to participate in interviews. Senior physicians generally have the lightest workload; they sit 60 ! ! up front by the patient intake room and occasionally supervise residents or sign off on paperwork. Therefore, senior physicians usually had the most time and were interested in participating in my project. Recruiting residents from the labor and delivery ward was significantly more challenging. First and second year residents in labor and delivery are so busy that during the lunch hour, they could be seen holding a sandwich in one hand and typing with the other. Since residents must work a 36-hour shift every three days, they were often so exhausted after their shifts that an interview with an Anthropology researcher was hardly of interest. After a few frustrating weeks of residents expressing interest in performing interviews but unable to take time to complete them, I realized that recruiting OB/GYN residents from labor and delivery would not be an effective strategy. Rather, I began to recruit OB/GYN residents working on the post-partum recovery floor. The work pace on the post-partum recovery floor tended to be slower, as in between morning and afternoon rounds, the residents were generally able to sit down and work on documentation. An additional challenge at both locations was finding a confidential space to perform the interviews. I initially had hoped to perform the interviews outside of the hospital, so that residents and senior physicians would feel at ease in sharing their opinions. However, it quickly became apparent to me that the residents had little enthusiasm in meeting for an interview in the small amount of time that they had free, as when I tried to finalize a time and place, residents often avoided committing to a plan. Thus, I decided that it would be easiest to perform the interviews in the hospitals whenever the physicians had a down moment. There were several logistical obstacles in finding an interview space. One challenge was that all physicians in the labor and 61 ! ! delivery ward must wear scrubs. If they leave the labor and delivery ward, they must change into an all white uniform. While interns regularly wear tight white pants under their scrubs to expedite the time it takes to run labs to other areas of the hospital, residents and senior physicians typically did not. Thus, it would take additional time to complete the interviews if we were to leave the labor and delivery area. In one of my first interviews, a senior physician suggested a small room just outside the labor and delivery area. Social workers sporadically worked on paperwork in this space, and were very accommodating in allowing me to use this room for 30-60 minute intervals for interviews. There was also a small room with a bed for fourth year residents just outside of the labor and delivery ward, and I utilized this space to perform interviews if the other room was occupied. For the interviews I performed on the post-partum recovery floor, the interviews took place in either an empty room or vacant part of the hallway. Hospital Pequeño proved to be more difficult than Hospital General in finding an interview space. Unlike Hospital General, there were no small rooms around the labor and delivery ward. Interns, residents, and senior physicians share a break room at Hospital Pequeño, so that area was very rarely vacant. If the delivery room at Hospital Pequeño was empty, the interviews took place there. If this space was occupied, I tried to find an empty area in the hallway surrounding the labor and delivery area to perform the interviews. For physicians at Hospital Pequeño working outside of the labor and delivery ward, there were substantially more options for interview spaces. There were frequently empty rooms in the post-partum recovery area, or a room with a bed for senior physicians to sleep in. 62 ! ! The inclusion criteria for this study consisted of residents and senior physicians in obstetrics and gynecology. As I began to shadow physicians in the post-partum recovery ward and labor and delivery ward, I asked physicians if they would be interested in a 3060 minute interview regarding delivery decision-making. None of the physicians that I invited to be interviewed declined or dropped out of the study. I performed follow-up interviews with four physicians in Hospital General. I asked additional questions that I had developed throughout the course of the interviews. However, I did not complete follow-up interviews for all physicians since I felt that data saturation had been reached and no additional trends had emerged. Table 1: Demographic Information of Research Participants Data Analysis Data analysis was an ongoing process throughout this research, as initial findings and early interviews were continually examined to develop the goals and questions in this study. Throughout the data collection process, I listened again to interview recordings and reviewed the comprehensive notes that I took during each semi-structured interview. I created a summary of all semi-structured interviews with a standard template that reflected the structure of the interview and topics that participants stressed as important. 63 ! ! When I returned from fieldwork, I sent all semi-structured interviews to VerbaLink for transcription. All interviews were transcribed in Spanish, and I utilized the Spanish transcripts for data analysis. After reading each interview transcript twice, I identified broad themes that emerged throughout the interviews. From these themes, I created a codebook of 49 codes utilizing Dedoose, a software system for analyzing qualitative data. During the coding process, I developed hierarchical classifications for the codes to capture as much detail as possible (Ryan and Bernard 2003). I defined each of the variables in my codebook to ensure that I consistently applied these codes. Additional codes were developed for observational data to fully capture these interactions. Some examples include “patient reprimands” and “discussion of birth control.” Several of these codes were developed a priori according to responses to a specific question. For example, I created a code for the question “What is the most common indication for a C-section in this hospital?” and created sub-codes for various responses, including medical reasons, cultural reasons, and institutional reasons. Most codes were developed in-situ, as I reread the interview transcripts and field notes. An example of a code developed in-situ is “patient characteristics.” I created multiple subcodes under this code, including urban vs. rural, education, physical characteristics, language, age, and behavior. I exported code application charts from Dedoose into Microsoft excel, so that I could further analyze the data to which codes were applied. This additionally allowed me to further examine trends within and between groups, such as residents and senior 64 ! ! physicians, physicians from the Yucatan and those from outside of the Yucatan, and responses from male and female physicians. These analytic techniques allowed me to incorporate both observed medical interactions and in-depth narratives from participants. Both observational data and semistructured interviews were critical in data analysis. The observational data enabled me to confirm or challenge ideas mentioned in the interviews, while the interviews often shed new light on observations. The following chapters of this dissertation will present the findings of this data analysis. ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 65 ! ! ! ! ! ! ! ! Chapter 4: “Here we don't really treat low-risk pregnancy as low-risk:” Physicians’ Perceptions of C-sections 66 ! ! It’s a sweltering August day at Hospital Pequeño. The tiny labor room of the Toco is nearly filled to capacity; pregnant women occupy six of the seven beds, fanning themselves with their hands or a scrap of paper as they breath deeply through their contractions. Except for an occasional moan from the laboring women, the room is silent. The interns sit on the floor or lean against the wall, fiddling with their phones or shutting their eyes in hopes of a restful moment as they wait for women to progress with their labor. One of the interns looks up for a moment to tell me that all six women are expected to have uncomplicated vaginal births, and so the interns now “just have to wait.” The interns snap to attention as they hear Dr. Mateo, a second year resident from Hospital General, enter the room. At 6 feet tall with a deep booming voice, Dr. Mateo hovers above the interns with a commanding presence. “How many births?” he asks an intern. The intern responded that there are six women in labor. “And how many centimeters?” demands Dr. Mateo. “Umm bed two is 3 centimeters (cm) and the rest are 6 cm,” the intern assesses. “Ok, time to break the membranes!” Dr. Mateo announces, as he grabs a long metal rod used to puncture the amniotic sac from a nearby table. Dr. Mateo passes the rod to an intern, directing the intern to break the water of a pregnant woman in bed 5, who is 6 cm dilated. The patient lies calmly in her bed, rubbing her belly, squeezing her eyes shut as the intern inserts the rod. The intern exchanges an alarmed glance with Dr. Mateo; there is some meconium in the fluid. “She’s an operation,” Dr. Mateo gruffly comments to the intern. Moments later, the intern begins to prep the patient for a Csection. -Field Notes, Hospital Pequeño, 10:30 AM August 8, 2016 Introduction Dr. Mateo’s management of this woman’s labor is hardly an uncommon situation at Hospital Pequeño and Hospital General. Dr. Mateo was the only resident assigned to the labor ward of the Toco this day, facing a full labor ward with women progressing at a relatively similar pace. Aware that he will not be able to supervise all of these births, Dr. Mateo attempts to speed up these women’s labor by breaking their water. When meconium appears in the amniotic fluid, he decides to operate. Medically, meconium stained amniotic fluid (MSAF) is not an indication for a C-section; in fact, researchers have demonstrated that a C-section in the case of MSAF provides no significant benefits over a vaginal delivery (Becker, et al. 2007; Caughey, et al. 2014; Van Bogaert and Misra 2008). Physicians at Hospital Pequeño and Hospital General were generally aware of 67 ! ! this recommendation; none of the residents or senior physicians interviewed listed MSAF as an indication for a C-section during our semi-structured interviews. Yet, none of the physicians working with Dr. Mateo, including the supervising attending physician, questioned or expressed concern at Dr. Mateo’s decision. Days later, when I mentioned this situation to one of the interns who had assisted on this case, he was unable to recall which patient I was talking about, noting this patient was one of eight or nine C-sections during his shift. Within the context of Hospital Pequeño, Dr. Mateo’s decision was unremarkable. This vignette highlights a paradox that arose regularly during my research at Hospital General and Hospital Pequeño: Physicians discussed specific indications for C-sections in our semi-structured interviews, but these reasons were rarely the actual cause of Csections in the Toco. Dr. Mateo’s story illustrates that while in theory physicians may not consider a particular condition an indication for a C-section, C-sections decisions may be reached quite differently in practice. Curiously, although physicians remain aware of this discrepancy, the story of Dr. Mateo also illuminates the routine, unquestioned role that Csections play in managing births in these hospitals. This chapter will explore physicians’ perspectives of why C-sections occur so frequently at Hospital General and Hospital Pequeño, examining how physicians renegotiate their ideas about how birth should best occur given the reality of their institution. Why C-sections Occur: Physician Perspectives on Delivery Method Physicians at Hospital General and Hospital Pequeño overwhelmingly stated that they believed that medical indications were the most frequent reason for a C-section in their respective hospitals. Within the first few minutes of each interview, I asked 68 ! ! physicians their opinion of the most common indication for C-sections at their hospitals. Their responses fall into several categories: medical, institutional, and cultural indications. I define medical indications as a response that entailed some form of pathology, such as pre-eclampsia, cephalic-pelvic disproportion or diabetes. I categorized intuitional indications as references to a particular aspect of the hospital context that contributed to C-sections, such as limitations in time and personnel, or the hospital’s position as a referral center for high-risk births. Finally, I classified cultural indications as a particular characteristic of the patient population to be the primary justification for a Csection. Such explanations include reasons such as Yucatan women being “chaparritas” (short stature), or a poor diet contributing to higher risk in pregnancy. While various medical, institutional, and cultural indications for C-sections arose throughout the course of the interview, here I will discuss physicians’ responses to the specific question “What is the most common indication for a C-section in this hospital?” I want to focus on these responses because they were obtained very early on in the interview and therefore were less susceptible to influence by questions that focused on various cultural, institutional, and medical elements of C-sections discussed throughout the rest of the interview. Nearly all of the senior physicians and residents at both Hospital General and Hospital Pequeño stated that a medical indication was the most common reasons for Csections, as 20 out of the 24 physicians interviewed gave a medical reason as an answer to this question. At Hospital General, the most common medical indication given by physicians was pre-eclampsia, a condition characterized by high blood pressure and protein in the urine during pregnancy. Other explanations included prolonged labor, 69 ! ! prematurity, or a previous C-sections. At Hospital Pequeño, the most frequent medical indication for a C-section described by physicians was cephalic-pelvic disproportion, a condition in which a woman’s pelvis is too small for the infant’s head. Although physicians felt that a medical indication explained most C-sections, the opening vignette of this chapter paints a more complicated picture of how such decisions are reached, as a medical indication clearly was not the sole reason for a C-section in this example. In order to understand why physicians felt medical reasons were responsible for the majority of C-sections, it is helpful to explore physicians’ underlying assumptions about childbirth. Childbirth as Risk The view of physicians at Hospital General and Hospital Pequeño that the technologic intervention of a C-section is justified by medical pathology aligns with the prevailing biomedical understanding of childbirth, as discussed in Chapter 2 (Ginsburg and Rapp 1991; Jordan 1992). Anthropologists note that biomedicine sees childbirth as a pathological event in which the obstetrician heavily relies on technology to manage the inherent danger associated with birth (Hahn 1987; Jordan 1997; Leavitt 1983). Jordan contends that cross-culturally, birth is a time of transition, leading to the development of particular behaviors and beliefs to manage this period of change. She writes, “We find that within any given system, birth practices appear standardized, ritualized, and even morally required routine” (1993:4). This statement is not to suggest that there is never risk associated with childbirth; rather, Jordan points out that as a cultural event, childbirth represents a period of unpredictability, thereby requiring different rituals to manage this uncertainty. 70 ! ! Risk was at the forefront of obstetricians’ concerns at Hospital General and Hospital Pequeño. Obstetricians at Hospital General and Hospital Pequeño described birth as a capricious event that could change in any given moment. One male 4th year resident explained that developing a process for making decisions is an important part of his obstetrical training, given the uncertain nature of birth. He explained: Mostly [during residency] what we learn is how to make a decision. The process of making a decision is important to learn because labor during childbirth is very dynamic… in any moment the decision to do a vaginal birth or operate, to do a Csection, can change. The notion that birth might suddenly turn into a perilous event was also reflected in senior physicians’ interviews. In describing the decision for a C-section, Dr. Joaquin, a senior physician at Hospital General, felt that childbirth could rapidly change from safe to dangerous, stating, “Well, it depends because in any moment [during labor] a relative indication can suddenly become absolute.” Dr. Joaquin’s mention of absolute indications refers to a handful of definitive cases in which a C-section is indicated, such as eclampsia, fetal acidosis, or placenta previa (Mylonas and Friese 2015). Rather, relative indications for C-sections are borderline cases, like pre-eclampsia or a previous Csection, in which a C-section is not a definite recommendation. However, Dr. Joaquin sees these cases as constantly subject to change; he feels that a birth without a previous indication can quickly transform to having one. Dr. Victor, also a senior physician at Hospital General, succinctly summarized the view that little differentiation exists between relative and absolute indications, stating, “Here we don't really treat a low-risk pregnancy as low-risk. We treat them like a highrisk pregnancy.” According to Dr. Victor, a low risk birth does not exist since birth in itself is a risky event. This point is additionally illustrated in the response of Dr. Juan, a 71 ! ! fourth year resident, to my question about an instance in which it was difficult to decide between a C-section and a vaginal birth. He stated: There was one woman who had oligohydramnios. And we initially were going operate but all the suddent she began to go into labor. Alone, just like that- she went into labor by herself! Then we saw that the birth kept progressing properly… obviously she had the indication for a C-section but we already had lot of work that day…Well the baby was born vaginally and nothing went wrong. Dr. Juan’s astonishment that a “riskier” case, a woman with oligohydramnios (a condition in which a woman has a low level of amniotic fluid), went into labor “alone, just like that” further illustrates the assumption that birth on its own begets danger. Rather than maintaining a baseline assumption that birth is a natural event that rarely requires intervention, Dr. Juan’s statement suggests he sees birth through the opposite lens: It is more suprising that birth was able to proceed without intensive technologic intervention. Monitoring and Guidelines: Mitigating Risk Physicians at Hospital General and Hospital Pequeño felt that a critical method for managing the inherent risk of birth was to monitor labor through technology and the presence of a physician. Almost all of the obstetricians interviewed mentioned monitoring the progression of labor as critical to their decision-making process regarding delivery method. Throughout the interviews, physicians expressed that medical personnel were essential to following the progression of labor. Dr. Patricia, a first year female resident, felt that the idea of childbirth proceeding unassisted by medical personnel was downright ridiculous, exclaiming, “They [laboring women] accumulate. Imagine if you’re working here and there are a thousand births and you give all the women a chance and sufficient time [to have a vaginal birth]. Imagine how overworked we’d be!” Implied in Dr. Patricia’s statement is that a physician must be present to manage vaginal births; 72 ! ! she feels that giving women long stretches of time to give birth vaginally is not feasible in Hospital General since physicians would have to be present for these births. Physicians also expressed that use of technology to monitor labor is critical to reducing risk. Dr. Valentina, a 46 year-old female senior physician at Hospital General, simply stated, “The first condition [for proceeding with] a vaginal birth is to be able to monitor it.” Dr. Valentina expanded on what she felt monitoring should entail, including an electronic fetal monitor, ultrasound, and senior physician to monitor labor in her description. Dr. Jesus, a senior physician at Hospital Pequeño, reiterated this view, noting, “With an ultrasound, a suitable monitor, we can have the security that we can follow the birth through [vaginally] without putting the baby at risk.” In Dr. Jesus’ description of technology as providing “security” for physicians, he expresses that technologic vigilance is essential to a “safe” birth. Senior physicians particularly emphasized the importance of guidelines in knowing how to utilize technology and manage risk. Four out of 9 senior physicians responded that in their opinion, “learning clinical guidelines” is the most important skill for residents to learn during training. Dr. Domingo, a senior physician at Hospital General, is one of two teaching instructors for the residents. He recently finished his residency at Hospital General, and has been working as a clinical instructor at Hospital General since. When I asked Dr. Domingo what he felt is most important to teach residents he answered, “Giving them the tools to know the criteria. We need to give them the guidelines to know when we need to operate or not.” Dr. Domingo’s emphasis on knowing guidelines was apparent during rounds with the residents. He routinely fired off questions at the residents, asking them questions like the guideline criteria for lab values 73 ! ! for pre-eclampsia, patients’ effacement, fetal heart beat, or progression of a patient’s labor based on clincal guidelines. Residents rarely volunteered to answer Dr. Domingo’s questions, often staring at the floor or busily jotting notes down to avoid being called on. When a resident did not know an answer to a question, Dr. Domingo often turned to an intern to answer, reprimanding the resident for not knowing facts that even an intern was familiar with. Before rounding with Dr. Domingo, residents could often be seen flipping through pages of large obstetrics textbooks in the interns’ pesara in preparation for Dr. Domingo’squestions. Rounds with Dr. Domingo continually reinforced his statement that “knowing the criteria” was of the uptmost importance for residencts. Physicians at Hospital General and Hospital Pequeño believed that birth itself if a risk. Technology is seen as central to managing the risk of birth, as it enhances their ability to meticulously “follow” labor in the hopes of avoiding potential complication. Senior physicians saw guidelines as important tools to determine when to intervene during childbirth. However, these beliefs were challenged in the context of the resource poor Mexican public hospital system, where technology like ultrasounds and electronic fetal monitors are sparse. In the next section of this chapter, I will explore how these physicians reconciled the realities of the public hospital environment with the belief that labor is a risky event that must be closely monitored. Construction of the “Medical Imaginary:” The Influence of Institutional Context on Physician Perception While physicians at Hospital General and Hospital Pequeño felt that technology is needed to monitor childbirth, they were continually challenged to put this idea into practice in the context of these hospitals. Both hospitals experienced a large patient 74 ! ! volume and lacked much of the technology that physicians had described in their interviews as necessary, like electronic fetal monitors and ultrasounds. Yet, physicians varied in their perspectives of how their work environment influences the use of technological interventions during childbirth. Senior physicians emphasized the shortcomings of this setting, viewing C-sections as a method to mitigate the risk of childbirth in the absence of the technology needed to monitor labor. In contrast, residents, particularly in their first two years of training, questioned how C-sections are utilized, and did not believe that C-sections were inevitable in the context of the Toco. To understand the varying points of view of those within the medical establishment, Delvecchio Good (2007) contends that it is critical to examine how certain groups perceive the potential effects of particular treatments, noting that these views may not align with reality. Observing that biomedicine often idealizes particular technologies and treatments, Delvecchio Good posits that a disconnect often exists between the medical community’s view of the potential that they see these interventions to hold, and the real effects of using them. She refers to the way in which individuals understand these interventions as “medical imaginaries,” defining the medical imaginary as “that which energizes medicine and makes it a fun and intriguing enterprise” (2007: 273). However, Delvecchio Good asserts that individuals occupying different positions within the medical institution may maintain varying constructions of the medical imaginary. Delvecchio Good posits that in order to understand the real effects of utilizing these interventions, we must first examine how different individuals in the medical institution create a distinctive medical imaginary. In her own work, Delvecchio Good found that the medical imaginary diverged for physicians of varying levels of training. For example, 75 ! ! Delvecchio Good found that oncology interns felt particularly disillusioned at how frequently senior physicians utilize the procedure of an autologous bone marrow transplant and how the senior physicians downplay the risks of the procedure (2007: 276). The concept of medical imaginaries is useful to analyze resident and senior physicians’ varying perspectives on why C-sections are excessively utilized in each hospital. In this section of the chapter, I will explore physicians’ views on how the institutional context in which they work influenced the use of C-section technology, and examine these differences within the theoretical framework of medical imaginaries. C-sections as Risk Management: Senior Physicians’ Perspective of Institutional Context In Hospital General and Hospital Pequeño, physicians’ adamant belief that they must monitor births in order to avoid potential risk conflicted with their work environments, in which they tend to a large number of patients with minimal technological resources. The lack of resources these hospitals was frequently mentioned, particularly by senior physicians. All seven senior physicians interviewed said that they did not feel all of the C-sections that occurred in their respective hospitals were medically necessary. Out of these senior physicians, all but one senior physician cited limited equipment and personnel as the reason for why not all C-sections were medically necessary, expressing distress at being unable to “know” a birth would proceed without complications. Dr. Sara, a 38-year-old female senior physician at Hospital General felt that excessive C-sections occur at Hospital General “because we don’t have other methods to confirm fetal wellbeing.” She explained further, “You’ve seen the ultrasound 76 ! ! we have here- it’s ancient. We don’t have a Doppler… we have two monitors, and sometimes like today-- look how many patients we have. So a lot of the times with making a decision, you have to think about what might follow.” To Dr. Sara, C-sections provide a mechanism to reduce risk in the absence of other technology, particularly given that the Toco could be full for the rest of the day. In her view, C-sections can alleviate the danger of a potentially full birth ward by ensuring that a physician is present for delivery. Senior physicians frequently mentioned the idea of anticipating complications yet feeling constrained in their ability to intervene should a complication arise. Dr. Jesús at Hospital Pequeño reaffirmed this idea, surmising that in the absence of technology, “In practice, sometimes we start to anticipate complications and think maybe it would be better to do the C-section.” Dr. Jesus’ statement that “in practice” physicians begin to expect complications acknowledges that the reality of Hospital Pequeño diverges from official obstetrical guidelines. Dr. Joaquin, a senior physician at Hospital General, described some of the institutional factors that he believes create a reality that varies from theoretical expectations for C-sections, explaining: Maybe it’ll take four more hours [for the patient to advance]. But in those four hours, you know that you’re going to have more C-sections. So then you have to think, “No, it’s better now because the fetus might suffer later and there’s no OR. Sometimes we have to make those kinds of decisions. In other words, because of a lack of resources, surgery, neonatologists, everything, so then, some Caesareans, in that sense, yes-- there isn’t a 100% justified cause. To Dr. Joaquin, with a large patient population and a lack of technology to monitor labor, C-sections offer a compromise through which physicians can attempt to ensure that no complications will follow an unsupervised vaginal birth. Delvecchio Good asserts in her description of medical imaginaries that it is not the proven efficacy of an intervention that matters, but rather the ideas associated with 77 ! ! that technology that are important. With the majority of senior physicians contending that not all C-sections that occur are medically necessary, they acknowledge that in theory a C-section is not the ideal intervention for many cases. Yet, “in practice” presents a different situation: senior physicians feel compelled to monitor births but note that their work environment limits their ability to do so. Thus, C-sections provide a tangible way to ensure that they supervise childbirth in the absence of other technology. C-sections create a new “imaginary” for senior physicians; they come to view C-sections as an assurance that they can mitigate risk in the absence of other technology. Like Dr. Sara and Dr. Jesus’ contention that one must think ahead to anticipate risk, C-sections offer a safeguard against the unknown. As Dr. Joaquin explains, particularly in an absence of personnel and technology to monitor labor, C-sections become the logical solution to manage this environment. C-sections become the “common sense” option to diminish risk when guidelines and standards can’t be followed. “They Don’t Give Women a Chance:” Residents’ Perspectives of Institutional Context Similar to senior physicians, all but one resident expressed that they felt not all Csections that occurred in Hospital General were medically necessary. However, unlike senior physicians, resident physicians were more likely to maintain a critical view of their work setting. About half of the residents interviewed expressed criticism towards how decisions for C-sections were reached at Hospital General. All except one resident who maintained this view were in the first two years of their medical training. Most of the residents that expressed this sentiment noted the subjectivity of senior physicians in making the decision for a C-section, observing that some senior physicians 78 ! ! were quick to perform a C-section without considering another option. Dr. Jamie, a first year male resident expressed, “The reality is that they [senior physicians] don’t give women a chance to have a vaginal birth.” Dr. Daniel, a second year resident explained that senior physicians’ opinions factor heavily into the decisions to let labor progress or to proceed with a C-section. He explained his view in discussing the case of prolonged labor: Prolonged labor is a difficult situation. Sometimes when the patient is fully dilated and the baby starts to descend down the birth canal, there are times when [senior physicians] say ‘Eh, she’s not progressing adequately.’ And we’ve previously examined the woman, we know that the baby isn’t big; we know that she has good uterine activity, we know that she has all the indications for a vaginal birth. But sometimes it takes a little while and the senior physician says, ‘You know what? It’s taking too long, we’re going to operate.’ Dr. Daniel highlights a paradox in his description: his medical knowledge and examination of this patient suggests that she would be fine to proceed with a vaginal birth, but the supervising senior physician feels a C-section would avoid any type of risk. Dr. Daniel is left in a difficult position; he faces the choice of following his medical judgment and challenging a senior physician or obeying the direction of a senior physician. A few of the residents critiqued other elements of their environment that influenced that the duration of labor, noting the chaotic setting of the Toco and guidelines that did not translate into practice as examples. Dr. Patricia, a first year resident offered this view on prolonged labor, explaining: Women who have never had children and who are only dilated a few centimeters upon admission- they’re laying down, they’re already nervous… and then the environment [of the Toco], it’s really loud, it’s stressful, and it scares them. I really think this influences them. 79 ! ! Dr. Anna, another female first year resident stated that she felt excessive C-sections occurred due to how guidelines are utilized in Hospital General. She referred to Friedman’s Curve, a graph regularly utilized by obstetricians to track the progression of labor, critiquing it for being difficult to apply as a universal standard. She explained, “The Freidman curve… it’s not significant evidence for you to say, ‘No [to a vaginal birth], she’s off the curve’ when still if you gave her a chance, she could advance.” This resident also raised concern about the impact of the Toco, noting it may serve to further amplify a woman’s deviation from the Freidman curve. She said, “We pressure the women from the moment they are admitted-in theory they should have progressed faster; but because of this [environment] they take longer. We have tried to say this, but well, the guidelines say otherwise.” Both Dr. Patricia and Dr. Anna note a disconnect between institutional expectations of patients and the reality of the Toco. These residents observe that guidelines utilized by physicians decontextualize patients from the environment of the Toco, resulting in an unrealistic expectation of how labor should progress. Residents further along in their training tended to reflect the responses of senior physicians. Similar to the senior physicians, two of the residents in their last two years of training blamed the lack of technology for unnecessary C-sections. In contrast, the other three residents in the first half of training felt that patient request for a C-section was the primary reason that not all C-sections were medically necessary. The more critical view of the hospital system held by residents who are earlier in their training may reflect that they are early in their socialization to this context. Numerous scholars have examined the process of medical training, suggesting a variety of methods through which “normal” individuals are transformed into biomedical 80 ! ! physicians. Byron Good (1994) describes medical training as a “formative process,” contending that the process of medical training encompasses more than learning facts, terminology, and procedures. Rather, students learn a “new world” in which “interpretive activities through which fundamental dimensions of reality are confronted, experienced, and elaborated” (1998: 68-69). Yet, as medical trainees immerse themselves in this “new world,” they regularly encounter situations that challenge their expectations or senses of morality (Beagan 2000; Hojat, et al. 2009). Delvecchio Good’s concept of medical imaginaries helps us to conceptualize the way in which newer physicians reconcile this discrepancy. As the residents at Hospital General become further immersed in the “new world” of obstetrics and gynecology, they become acquainted with a reality that diverges from their previous learning. Residents question elements of their environment, such as the use of strict guidelines and the pressure to move patients through the system. Newer residents are alarmed by aspects of their work setting, like women not being “given a chance” to have a vaginal birth or acknowledging that the stressful environment of the Toco alters women’s progression of labor. These dynamics create somewhat of a contradiction for the residents; the decisions made in the Toco do not always align with the residents’ intuition or previous knowledge regarding childbirth. Given that they are new to the world of obstetrics, the residents must abide by the directions of their senior physicians. In the residents’ responses, an “imaginary” is created: if women were given more time or if women weren’t placed in such chaotic conditions, perhaps the course of childbirth could proceed differently. These residents are hopeful that such births could occur without such intensive intervention under a different context. 81 ! ! The imaginary of these residents contrasts sharply with that of the senior physicians. Both senior physicians and residents recognize the limitations of their respective hospitals; they create a different imaginary to conceptualize this environment. Senior physicians express an imaginary in which C-sections provide a safeguard against risk in the absence of other options. In contrast, while residents are aware of the shortcomings of the Toco, they do not view C-sections as the common sense response to manage risk. Dr. Daniel and Dr. Jamie critique senior physicians for quickly rushing to a C-section without considering a vaginal birth. Dr. Patricia and Dr. Anna observe elements of their work setting that may influence the course of labor, such as the stressful environment of the Toco on how quickly women dilate. While these younger residents believe that not all C-sections are necessary, the responses of residents later in their training suggest that such hopes may diminish with time. In exploring why residents earlier in their training expressed more criticism regarding excessive C-sections, it is important to consider their position within the medical system. Young physicians were often eager to gain more clinical experience, but their ability to do so depended on their year of training and the hospital that they were in. For example, at Hospital General, residents do not perform C-sections until their third year, while at Hospital Pequeño, second year residents are able to participate in Csections. Residents were often excited for the opportunity to practice their surgical skills; several of the residents I interviewed explained that they enjoyed their time at Hospital Pequeño in part because they were able to perform procedures like C-sections. Residents’ enthusiasm for gaining surgical skill could explain why their perspectives change throughout time. 82 ! ! Additionally, it remains important to note that while residents who were in earlier stages of their training remained more critical in their views of excessive C-sections during their interviews, their beliefs were not reflected in how they acted. As the example of Dr. Mateo at the beginning of the chapter illustrates, residents may be quick to decide to perform a C-section when a minor indication arose. Again, physicians’ eagerness to improve their surgical skill could explain why they criticized excessive C-sections during our interviews, but did not hesitate to perform them in practice. Another possible explanation for the discrepancy between residents’ statements and actions could be the medical hierarchy between residents and senior physicians, a concept that will be further explored in the next chapter. Conclusion This chapter began with presenting the reasons physicians gave for performing Csections, highlighting that the majority of residents and senior physicians felt medical rationales explained most C-sections at these hospitals. In examining why physicians feel that medical indications explain most C-sections, I observed that physicians at Hospital Pequeño and Hospital General maintain an underlying assumption that birth is a dangerous event in need of monitoring through technology and regular assessments by biomedical personnel. I then explored how the specific settings of Hospital Pequeño and Hospital General challenge this idea, given that limited resources in both hospitals constrain physicians’ ability to monitor labor. I employed Delvecchio Good’s theory of medical imaginaries to analyze how senior physicians and residents reconcile the reality of the Toco with their beliefs. I asserted that senior physicians create an imaginary in which C-sections become the “common sense” way to manage risk, whereas residents’ 83 ! ! imaginary holds that a C-section is heavily influenced by elements of their institution, and is often an unnecessary intervention. The intention of this chapter is not to suggest that C-sections are never necessary or life saving procedures. Rather, I aim to illustrate the way in which social, cultural, and institutional variables uniquely shape the perspectives of providers of different positions in these hospitals. Illuminating these factors is critical to understanding that such decisions are not neutral or solely medically based, but rather that they are closely tied to the cultural context in which they occur. In utilizing the idea of the medical imaginary, I aim to highlight how senior physicians come to understand C-sections as a mechanism through which risk can be reduced when their work setting challenges their beliefs, whereas residents view these decisions as unnecessary. However, it is important to note that residents’ opinions were not always reflected in their actions; many of the residents remained eager for the opportunity to enhance their clinical skill. While I identified that senior physicians and residents construct varying medical imaginaries to contend with the challenges of their hospitals, questions remain regarding why their perceptions might differ. For example, how do senior physicians perceive the consequences of a “risky” birth? Why might residents’ actions not reflect their beliefs about delivery method? How do residents become socialized to the medical imaginary of senior physicians? Finally, how might larger politico-economic pressures of a neoliberal health system shape institutional demands? What is the effect of these requirements on physicians? Chapter 5 will explore these questions. ! ! 84 ! ! Chapter 5: “It’s not really a punishment; it’s an incentive to do better:” Data Performativity, Responsibility, and Blame at Hospital General and Hospital Pequeño 85 ! ! “The C-section rate here in the Yucatan is difficult because we haven't been able to identify one significant factor to focus on. You know, everyone gives an opinion on it… it’s because [the doctors] don't want to spend the time with a natural delivery or everyone's in a hurry or the patient herself requests a C-section. But, those are all sort of, you know, personal experiences. We don't have anything specific to say there's an error in a decision or what exactly is causing that decision to be made. My opinion is that it's a demand on the health system. We've been thinking we need to have a format or some sort of questionnaire for which every delivery by C-section you have to specify certain things as to why you did it or... It seems very controlling, we haven't really agreed that that will be a solution…to at least finding, identifying the cause of this increase.” -Dr. Valeria, administrator at the Yucatan Ministry of Health, August 22, 2016 Introduction Dr. Valeria expresses a paradox in her explanation of why C-section rates remain high in hospitals accepting Seguro Popular in the Yucatan. On one hand, she acknowledges the complexity of the public hospital environment by mentioning the “demand on the health system.” As Seguro Popular has continued to expand without adequate funding, Dr. Valeria recognizes the challenging environment within which physicians must make decisions. However, Dr. Valeria sharply pivots in her next statement, as she describes the Ministry of Health’s attempts to understand the C-section rate. Rather than conceptualizing C-section rates within a complex political, social, and economic environment of public hospitals, she suggests that some sort of standardized decision-making process for C-sections could help to alleviate the issue of a high Csection rate. Furthermore, requiring physicians to document reasons for C-sections would allow for the quantification of particular justifications, neatly extracting data from the messy and complicated environment of the public hospital. In Dr. Valeria’s remark that such a system could aid in “finding the cause of the increase,” she implies that the 86 ! ! problem of an elevated C-section rate could be simplified to a handful of measurable causes. Dr. Valeria’s statement lends insight into how administrators come to understand multifaceted situations as easily reducible to simplified data points. This chapter aims to explore how particular measurements, like the C-section rate and the maternal mortality rate (MMR) gain importance and variably influence physicians at different levels of the health care system. I will examine how particular metrics hold varying meaning for different actors in the health care system, observing how an individual’s understanding of these measures shapes their actions. Data Performativity In conceptualizing how metrics take on meaning, Erikson’s (2012) concept of “data performativity” is helpful. Erikson utilizes the term data performativity to describe how metrics inherently structure the data that is collected. Examining the production of maternal health statistics in Sierra Leon and Germany, Erikson writes, “Whether statistics are accurate enough to improve health is less important than whether statistics are performed and work to enable economic systems” (2012:373). In this statement, Erikson observes that the potential of data to impact health and wellness becomes secondary to the meaning that data holds for particular actors. Thus, she contends that data comes to be “performed;” the outcomes “revealed” by the data are created by the parameters used to collect these numbers and how individuals gathering the data understand this process. Erikson asserts that ultimately, that data is structured by how it is collected, rather than a neutral reflection of reality. Erikson’s concept of data performativity is particularly illuminating in the context of maternal health at Hospital General and Hospital Pequeño, 87 ! ! given the multiplicity of actors involved in generating data regarding maternal health. I will employ data performativity as a framework throughout this chapter to better understand how the emphasis on particular outcomes shapes the decisions of health care administrators, senior physicians, and residents at these hospitals. Countdown to 2030: Mexico and Maternal Mortality Before examining how particular measurements come to hold different meaning to varying actors in the health care system, a brief discussion of MMR in Mexico provides context for understanding how this statistic gained importance. Beginning in 1990, the United Nations (UN) established eight Millennial Development Goals (MDGs) to achieve by 2015 in the hopes of “galvanizing unprecedented efforts to meet the needs of the world’s poor” (United Nations 2015). One of these goals was to reduce MMR by two thirds by 2015. While the UN touted this goal as a success in many countries, a handful of nations failed to achieve this benchmark. The World Health Organization (WHO) subsequently established the “Countdown to 2030” (CD2030) in 2015 with the intent of reducing MMR and infant mortality rates (IMR) in countries that had not attained the original goal. CD2030 aims to reduce MMR and IMR in 75 countries that account for 95% of maternal, newborn, and child deaths through “evidence based solutions” (World Health Organization 2015). While Mexico achieved most of the MDGs by 2015, they did not meet the MDG for MMR. Hence, Mexico has been added to the CD2030, specifically monitored for MMR. Despite concerted efforts to reduce MMR, such as conditional cash transfer programs, increasing hospitalized birth, and expanding Seguro Popular, Mexico still has not attained this benchmark (Blanc, et al. 2016). 88 ! ! Meanwhile, social scientists have largely questioned whether MMR is an accurate indicator of women’s wellbeing, pointing out that solely considering whether a woman lives or dies during childbirth as the standard of success obscures many other facets of health, such as women’s desires and experiences during childbirth (Adams, et al. 2016; Berry 2013). Additionally, social scientists have highlighted the difficulty in calculating a precise MMR, given that maternal deaths are often unreported and that the MMR calculation only considers death within a particular time span to constitute maternal death (Storeng and Béhague 2017; Wendland 2016). Yet, as discussed in Chapter 1, the accuracy of such numbers comes to matter less than the meaning that they take on (Adams 2016). Metrics like MMR are deeply intertwined with politics, as the MMR has come to be seen as an indication of the success or failure of particular political leaders (Erikson 2012; Oni-Orisan 2016). Researchers are beginning to observe the impact of the emphasis on lowering MMR in Mexico, as some researchers question how such data is reported. For example, in the Yucatan Peninsula, several accounts have noted that the production of an accurate MMR has been particularly problematic, as multiple instances of omitting maternal death or altering morbidity and mortality statistics have been documented (Rodríguez-Angulo, et al. 2009; Williams 2016). For example, Williams (2016) found that physicians in a private hospital in Tulum, Mexico, may alter the entry of data to appear more favorable. She details the account of a patient who experienced an unplanned, emergency C-section. Yet, Williams asserts that the reality of this situation was not reflected in the patient’s medical record; her medical record stated that this patient had a planned, uncomplicated C-section. While I did not find any evidence of overt data manipulation, similar to 89 ! ! Williams, I observed that administrators from Hospital General, Hospital Pequeño, and the Yucatan Ministry of Health viewed MMR as a critical measure of success. Metrics and Evaluations at the Yucatan Ministry of Health In order to understand how physicians at different positions in the health care system perceive their responsibilities and subsequent consequences for not fulfilling these duties, it is helpful to briefly examine the evaluation process for SSA hospitals that accept Seguro Popular. As no official document outlining this process is available to the public, I will draw on insights from my interviews with three physicians working in high level administration at Hospital General, Hospital Pequeño, and the Yucatan Ministry of Health to explain the evaluation procedure. I met Dr. Valeria, the physician quoted at the beginning of this chapter, by chance in the summer of 2016. After weeks of trying to obtain an interview with any Ministry of Health official, a colleague from my university introduced us at a research presentation at the Ministry of Health. Tottering on very high heels with her hair tightly pulled back, Dr. Valeria excitedly described to me upcoming projects at the Ministry of Health. She describes her position as helping to oversee women’s health in the hospitals accepting Seguro Popular in the state of the Yucatan, helping to develop new programs in these hospitals and assessing these hospitals several times a year to ensure they are meeting the standards set by the national Ministry of Health. Dr. Valeria agreed to sit down for a few minutes to answer my questions about hospitals that accept Seguro Popular. We ended up talking for almost an hour. According to Dr. Valeria, hospitals that accept Seguro Popular are evaluated every three months by the federal government through electronically submitting data. She 90 ! ! told me that the federal government evaluates all of the hospitals utilizing Seguro Popular in the state of the Yucatan as a whole; for women’s health, the federal government sees combined data from the six maternity hospitals in the state. Dr. Valeria said that hospitals are evaluated on six indicators, with some weighted more heavily than others. She notes that the indicators, “…should be in the expected range but I guess especially with maternal mortality. If that one is way above what is expected, that one is enough [for the federal government] to send... send things to us.” In terms of what the federal government might “send,” Dr. Valeria explains, “the federal government sends a team to investigate." After the federal government’s visit to the state, Dr. Valeria explains that federal government provides the state with a written report of their findings and suggestions to improve. The federal government follows up several months later to check if progress has been made towards these indicators. I asked Dr. Valeria about the consequences of not meeting these indicators: Interviewer: .So, if you're in last place compared to the other states then it's likely that you will not be funded the same as the hospital in the first place? Dr. Valeria: Yes, exactly. Because you're not making sufficient effort to improve your indicators. It hasn't happened to us but we've heard of some states that have been punished in this way. Well, it's not really a punishment it's an incentive to do better. Dr. Valeria’s comment that states that are not “making sufficient effort to improve indicators” implicates that a failure to fulfill particular metrics must be attributed to a lack of trying. Ultimately, she explains that a hospital that fails to meet these indicators may loose federal funding. She asserts, “If that [federal funding] is removed a very substantial amount of funding would no longer exist and we would depend only on state financing and that would be a serious blow to the program.” Thus, maternal mortality becomes a 91 ! ! critical measure of success, reflecting the efforts of the Yucatan Ministry of Health. Maternal mortality statistics are a top priority at the Ministry of Health; in addition the “punishment” of loosing funding for health care, a poor MMR would mean failure for the personnel at the Ministry of Health. However, Dr. Valeria notes that not all indicators are weighted equally. Dr. Valeria noted that the Yucatan has consistently remained above the federal government’s suggested C-section rate of 25%, but has not lost funding. She felt that the C-section rate alone was not sufficient to yield consequences. While the data that the federal government sees is for all of the hospitals accepting Seguro Popular combined, Dr. Valeria explains that the Yucatan Ministry of Health can view and evaluate the data from each hospital individually. Dr. Valeria explained that the Ministry of Health first sends a letter to an individual hospital, “asking them to do such and such a thing or change this or improve or regulate control.” She notes that if that hospital still does not improve, the State Health Department will send an employee to “supervise” that hospital, and to more clearly identify areas that need improvement. If these measures do not succeed, “the last option” is to change personnel at the offending hospital. Administrators at both Hospital General and Hospital Pequeño were acutely aware of the possibility of personnel being changed if things didn’t improve, as the director of Hospital Pequeño had been replaced several months prior to my visit in the summer of 2016. In the next section of this chapter, I will explore how physicians working as hospital administrators perceived the priorities of the Ministry of Health, and their respective roles in data performativity. 92 ! ! Good Behavior and Good Numbers: Administrative Physicians’ Perceptions of Metrics and Responsibility I interviewed a high-ranking administrator at both Hospital General and Hospital Pequeño. I interviewed Dr. Santiago at Hospital General. He has worked as a senior physician there for over 25 years; he was promoted to an administrative position in the winter of 2016. Donning a white coat over a crisply ironed shirt and tie, Dr. Santiago has a serious but polite demeanor. I spoke with Dr. Santiago during two 45-minute interviews, which took place in his office at Hospital General; the only room in the obstetrics ward with air conditioning. At Hospital Pequeño, I spoke with Dr. Isabella, a senior physician who had worked as an administrator at Hospital General for the last three years, and switched to Hospital Pequeño in the winter of 2016. I had struggled to obtain an interview with Dr. Isabella; I was given times and dates to meet with her on three separate occasions, only to be told that she was unavailable when I arrived. Finally, in the last few weeks of August 2016, Dr. Isabella met with me for a 45-minute interview. Several days later, we had a follow-up interview that lasted about 45 minutes. With bright pink lipstick and long pink acrylic nails, Dr. Isabella often became animated during our talks, particularly in discussing her plans for turning Hospital Pequeño into a “premiere” hospital in the region. Echoing the goals of the Ministry of Health, Dr. Isabella listed her primary goals as an administrator at Hospital Pequeño as achieving the goals of Mexico’s 2012- 2016 Maternal and Perinatal Development Plan, a document created by the Mexican Ministry of Health detailing health goals for the next four years. She stated that she ultimately hopes that Hospital Pequeño will “return to being a maternal and perinatal hospital of 93 ! ! excellence.” I asked Dr. Isabella which of the goals from the 2012- 2016 Maternal and Perinatal Development Plan were most important at Hospital Pequeño. She responded, “Really to reduce maternal mortality. For us to focus on risks, or to always find the reason for a risk, and through this to avoid a large number of severe or extreme maternal morbidity [cases].” Dr. Santiago also stated the importance of reducing MMR. When I asked Dr. Santiago what his goals for Hospital General are, he replied, “Reducing maternal mortality- this is the first goal. Reducing maternal morality, and improving the education process for specialists in this hospital.” Both Dr. Isabella and Dr. Santiago were acutely aware of the Ministry of Health’s emphasis on MMR, as a focus on the MMR emerged as a top priority for their hospitals. Curiously, in contrast to opinions of the senior physicians and residents discussed in Chapter 4, neither administrator thought that a high C-section rate was an issue at their hospital. I asked both administrators early in the interview if they thought that C-section rates were high at their respective hospitals. Dr. Isabella responded: Fortunately no. There are more vaginal births than C-sections [here]. I think in Hospital General the problem is that they are a third tier hospital, and all the complicated births from the state arrive there… But us, we’re not a resolution hospital like Hospital General… this lets us make more tangible decisions that guide women towards a vaginal birth. Dr. Isabella expresses that because there are more vaginal births than C-sections at the Hospital Pequeño, she feels it does not have a high C-section rate. Additionally, she states Hospital Pequeño’s status as a second tier hospital (a hospital with limited services) means that they receive less complicated patients, and are able to spend sufficient time with women to give a vaginal birth. She believes that Hospital Pequeño’s C-section rate of 41% is not problematic, particularly compared to Hospital General. 94 ! ! Similarly, Dr. Santiago did not see Hospital General’s C-section rate of 55% as problematic. In response to my asking if the C-section rate is high in this hospital, he said, “Well, I think it is what it should be in this hospital. It could be high for other hospitals, but for this hospital I think that’s correct.” Dr. Santiago feels that Hospital General’s status as a third tier hospital (meaning that this hospital offers the greatest number of services) results in receiving patients with more complicated pathologies. He adds that many patients arrive late to the hospital, noting, “Most patients don’t arrive in the condition that we’d hoped.” Like Dr. Isabella, Dr. Santiago does not see the number of C-sections at his hospital as excessive; he feels that they are justified given the patient population at Hospital General. Both Dr. Isabella and Dr. Santiago were aware of how the hospital evaluation process functioned. Dr. Santiago explained that Hospital General’s Department of Quality Management fills out a “pre-established” form for the director of the hospital to send to the Yucatan Ministry of Health. I asked Dr. Santiago for an example of the preestablished evaluation criteria and he said they include metrics like “numbers of patients treated, how many patients died, the duration of their stay in the hospital, and if an autopsy was performed [if a patient died].” He reiterated once again, “On our side... the big commitment right now is to lower the number of maternal deaths.” I asked Dr. Santiago what would happen if they failed to meet these goals. He elaborated: Well it depends. There are different procedures that can happen. One is creating an analysis to examine causes or why the circumstances led to this outcome and to see if you can solve these problems. The director of the hospital has to make an analysis and immediately take the actions that the state government gives us. If we send them a number above what they expected, we don’t only give them the information ‘I had 12 maternal deaths. We are below the national guideline by two.’ [Ministry of Health will ask] ‘Okay but how can you lower it more?’ Or, I 95 ! ! can say, ‘We have this [number] and it was because this and that. We did this and that thing.’ From this comment, we see that Dr. Santiago believes that the data produced is not a rigid set of numbers, but rather part of a negotiable process. Dr. Santiago’s expression that “I had 12 maternal deaths” implicates that he is personally responsible for such a statistic. Yet in his remark “We have this number because of this and that,” he implies that changing particular elements surrounding maternal mortality could result in a different outcome. Furthermore, this remark implies that maternal death can be readily explained by a handful of factors. To Dr. Santiago, the production of data is not final, but rather flexible with room for improvement. He acknowledges that the Yucatan Ministry of Health will not view a high MMR favorably, but sees his relationship with the Ministry of Health as dynamic, as they work together to produce different data, consistent with the concept of data performativity. Yet, in working collaboratively to produce better data, Dr. Santiago finds the importance of Hospital General’s MMR to be its relationship to the national average, rather than any meaningful improvement in women’s health. In Dr. Santiago’s statement, he focuses on numerical values and the government’s impression of those quantities, rather than factors like patient experience, long-term health, or other social, political, and cultural factors that could have contributed to the deaths of these women. Dr. Santiago sees distinct benefits to maintaining favorable statistics to send to the Ministry of Health. I asked Dr. Santiago if meeting the criteria from the Ministry of Health meant that the hospital received more funding. He explained that while the hospital doesn’t directly receive extra money for meeting particular requirements, 96 ! ! Ministry of Health viewing Hospital General in a positive light might provide more leverage for the hospital when in need of particular resources. He explained: Everything is correlated. If I’m achieving good goals, then I can ask for more. It’s like having a son or daughter. If they want to go out, what do they do? They behave well, finish their schoolwork, finish their job, and then ask ‘Can I go out?’ Yes! ‘Can I go out tomorrow also?’ ‘If you have behaved well, then yes!’ So, this is the logic… while a person is doing well with things and then asking you for something, you have confidence that you can give them more liberty and opportunities. Dr. Santiago’s comparison of the “good behavior” of the hospital (i.e. meeting the benchmarks required by the Ministry of Health) to a parent rewarding a child for completing his or her chores highlights the varying goals of different actors in the health care system. Dr. Santiago feels that if Hospital General aligns it’s goals with those of the Yucatan Ministry of health by achieving favorable metrics for this hospital, he believes that this may result in favorable treatment of the hospital. It is important to recognize that underlying his statement is his assumption that both he and the Yucatan Ministry of health share the same goal: to generate “good” numbers. Dr. Santiago’s assumption that different actors within the health care system maintain the same priorities also applies to his view of the physicians in Hospital General, as he extended his analogy about children behaving well to the physicians at his hospital. He elaborated, “It’s like that with my doctors here. If they’re not accomplishing what I ask and they’re not helping me, when they ask me for something, I have to think about it.” Dr. Santiago implies with this statement that the senior physicians and residents’ goals should align with his and those of the institution; namely reducing maternal mortality. Similar to his relationship with the Yucatan Ministry of Health, Dr. 97 ! ! Santiago feels that if physicians help to achieve institutional goals, then he will be more willing to accommodate whatever requests those physicians may have. At the same time, having worked as a senior physician in Hospital General for nearly three decades, Dr. Santiago recognizes challenges that physicians in Hospital General may face and other priorities that physicians may hold. He explained, “We have a huge number of patients in labor and only one doctor to attend to them at times... We lack many resources and in those situations, you [as a physician] need to think about what benefits the patient.” Dr. Santiago expresses two distinct goals in his statements; while he feels that physicians should work in a manner that benefits the patient, he also expects physicians to fulfill institutional goals. Dr. Santiago does not seem to see these goals as opposing; he feels that what is best for the patient also benefits the hospital, assuming that physicians will work towards these goals. Yet, as I will discuss later in this chapter, senior physicians and residents held notably different priorities than Dr. Santiago. Like Dr. Santiago, Dr. Isabella provided a similar description of the evaluation process at Hospital Pequeño, emphasizing the importance of lowering the MMR. She explained that the Department of Quality Management at Hospital Pequeño creates a report to send to the Yucatan Ministry of Health, and subsequently the national government. In her explanation, she also emphasized that in the evaluation, “…they’re continuing to observe our maternal mortality rate.” I asked Dr. Isabella what would happen if Hospital Pequeño did not meet the goals established by the Ministry of Health. She explained that this could potentially mean that Hospital Pequeño would lose their accreditation status, thereby losing funding. Dr. Isabella says this was previously a concern for Hospital Pequeño prior to her employment there, noting that Hospital 98 ! ! Pequeño was “off the map” before she arrived to make changes. Dr. Isabella described one such change she has instated to improve Hospital Pequeño’s evaluations: We still have a long way to go, but we’re beginning to adapt to the [federal government’s] Development Plan and to meeting our goal, reducing maternal mortality. From the 30th of this month onwards, a prevention committee at the hospital will meet to monitor maternal and perinatal morbidity and mortality, and we intend to search for ‘critical links.’ What’s this? For patients who have had the term ‘severe morbidity’ applied to them, we’re going to look to see where the link was [between that morbidity and the outcome]. It’s not with the intention of assigning blame; to the contrary, we’re trying to learn and improve. If things went well, we’ll keep up that momentum. If not, we need to modify the way we’re attending to patients. Dr. Isabella views the maternal mortality “prevention committee” as an innovative method to scrutinize the causes of poor outcomes. Like Dr. Valeria, Dr. Isabella feels that with proper analysis, a handful of causes can explain a particular outcome. While Dr. Isabella feels that the intent of the prevention committee is not assigning blame, looking for a “link” or a cause that contributed to a particular outcome inevitably assigns responsibility to a patient, physician, or other element of the patient’s care. Dr. Isabella sees this committee as important to improve Hospital Pequeño’s data. Dr. Isabella asserts that a critical component to Hospital Pequeño attaining favorable metrics is the role of the patient. She explained: We’re teaching them [the patients] to think ‘I’m pregnant-- now what? Where will I go for appointments, how will I get there, what are signs that something is wrong?’ Ultimately we’re teaching them that my health doesn’t depend on my doctor, it depends on me… And we’re giving them the information, teaching, and options to do that. Dr. Isabella makes an important assumption in her statement; she feels that if patients at Hospital Pequeño were well educated about pregnancy, they would maintain a similar goal to the hospital administration: achieving a “good” outcome for their pregnancy. By providing patients with additional information, Dr. Isabella feels that patients will 99 ! ! embrace responsibility for their pregnancies, taking the necessary steps to ensure a healthy pregnancy and safe delivery. Dr. Isabella assumes that this outcome must be what patients at Hospital Pequeño strive for during their pregnancies yet feels the reason they currently do not engage in such behaviors is a lack of education. Both Dr. Santiago and Dr. Isabella felt that reducing the MMR was the principal goal of their respective hospitals, observing the importance of a low MMR to the Yucatan Ministry of Health. Both administrators saw this metric as more significant than the Csection rate in their hospitals, viewing their hospitals’ C-section rate as unproblematic. Implicit in both administrators’ statements was the assumption that lowering the MMR by ensuring a safe delivery was also the primary goal of other actors in the health care system. Dr. Santiago felt that physicians working at Hospital General share his goal of decreasing the MMR, seeing their participation in helping to achieve institutional goals as laudable. While he acknowledges the challenges of the public hospital for physicians, he assumes that physicians will work in the best interests of their patients, namely through a providing a safe delivery. Dr. Isabella holds similar thoughts about patients at Hospital Pequeño, feeling that if patients were adequately educated, their primary goal would be to engage in behaviors that promote a good outcome for their pregnancy. However, as I will explore in the next section of this chapter, residents and senior physicians’ perceptions of their work environment often led to them holding different priorities from that of the administration. Physicians’ Perceptions of Responsibility and Institutional Goals Many of the physicians that I interviewed expressed an awareness of the hospital administration’s MMR goals. As I discussed above, lowering the C-section rate seemed 100 ! ! to be a secondary concern for the Yucatan Ministry of Health. Dr. Santiago and Dr. Isabella also reflected this sentiment in my interviews with them, as Dr. Santiago viewed the C-section rate in Hospital General as “what it should be” and Dr. Isabella didn’t feel that Hospital Pequeño had a high C-section rate at all. Senior physicians and residents echoed these thoughts in our interviews. I asked all of the physicians interviewed what they thought about the hospital administration’s stance on the C-section rates in their respective institutions. Approximately half of the physicians responded that they felt the administration was either indifferent to or agreed with the C-section rate. Dr. Jesus, a fourth year resident explained, “I think they [the administration] supports the C-section rate here. It’s not that they want it to be high. It’s that they realize [this rate] is necessary here.” Similar to Dr. Santiago, Dr. Jesus feels that the administration does not encourage C-sections, but understands them as necessary in the context of this hospital. Other physicians felt that the hospital administration was indifferent to the C-section rate in their hospital, citing a trust in physicians’ clinical judgment as the reason why. Dr. Sebastian, a senior physician with 18 years of experience at Hospital General explained, “The hospital accepts our decision. If you say that’s an operation, that’s an operation, and that one too; they don’t question it.” Dr. Joaquin, also a senior physician at Hospital General reiterated this thought, saying, “Really I think they’re indifferent to it. Or it’s more of ‘You figure this one out…’ So it’s not like they tell you, ‘if you have to operate, do it.’ [The decision] is based on what we say, it’s your own responsibility.” Dr. Sebastian and Dr. Joaquin feel that the hospital trusts physicians’ opinions of when Csections should be utilized and do not actively discourage C-sections from occurring. 101 ! ! About half of the physicians stated that their respective hospitals discouraged high C-section rates and wanted to lower the rate at their respective hospitals. However, in many of these responses, physicians pointed to a difference between what the hospital’s administration said as their official stance and what they encouraged in practice. For example, Dr. Rafael, a second year resident stated that he felt that the administration at Hospital General “says we should lower the C-section rate and operate less. That’s the official position. But the unofficial position seems more like yeah, go ahead.” Other physicians felt that while the hospital officially stated C-sections should be lowered, achieving this was not logistically feasible in their hospital. One senior physician at Hospital General explained, “Well, I think there’s pressure from the authorities to lower the C-section rate. But with the population we work with and the resources we have, the truth is that’s very difficult to do.” Most of the physicians who said that the hospital officially “discouraged” a high C-section rate added a similar disclaimer, noting that the administration realizes that lowering the C-section rate is difficult, due to complicated patients, a lack of resources, or being a referral hospital. Thus, both senior physicians and residents reported that while the administration might officially state that C-sections should be reduced, little is done on behalf of the administration to discourage C-sections. I argued in Chapter 4 that senior physicians come to understand C-sections as a method to monitor childbirth in the absence of other technology. Physicians’ perception that few consequences exist for performing a large number of C-sections helps to provide additional support for this contention. While hospital administrators are concerned with whether C-section rates are an important indicator for the Ministry of Health, practicing physicians at both hospitals were less 102 ! ! concerned with the Yucatan’s Ministry of Health criteria, and more focused on administrative indifference to C-section rates within their own institution. Maternal mortality rate impacted practicing physicians differently than the hospital administration as well. I discussed above that hospital administrators fixated on MMR as a marker of success for their hospitals, knowing that such statistics are critically important to the Ministry of Health. While senior physicians and residents also recognized birth outcome as important, their perception of why outcome mattered varied immensely from that of the Ministry of Health and the hospital administration. Avoiding “La Demanda”: Senior Physicians’ Perspectives on Outcome The senior physicians all felt that their respective hospitals recognized that Csections are necessary, and did not express a concern of repercussions for performing a large number of C-sections. Rather, the most frequent concern that senior physicians discussed was the fear of legal ramifications for a poor outcome. All of the senior physicians interviewed mention the fear of getting sued at least once throughout the course of our interview. Physicians at Hospital General and Hospital Pequeño most frequently discussed the fear of legal consequences in the context of violencia obstetrica (obstetric violence). Starting in 2007, a handful of states in Mexico added obstetric violence as a legal offense to the “General Law on Women's Access to a Life Free of Violence”, defining this as inefficient attention, lack of informed consent, and treatment causing “harm to the health and integrity of women” (Secretaría de Relaciones Exteriores 2007). Excessive intervention, including episiotomies, vaginal exams, and unnecessary C-sections are included under this law. In 2014, the Mexican senate voted to incorporate obstetric 103 ! ! violence into national law (Senado de la Republica 2014). The penalty of violating this law varies by state, typically involving a fine and possibly several months of jail time. However, this law does not have clearly established routes for women to press charges and in practice, lawsuits involving obstetric violence are nearly unheard of, with only extreme cases of maternal or infant death having resulted in an investigation (Castro and Erviti 2015). Despite the paucity of prosecutions under this law, a fear of being accused of obstetric violence through a demanda (lawsuit) was frequently mentioned among participants. Dr. Sara, a senior physician at Hospital General explained her perception of obstetric violence to me: There’s a lot of fear right now about the obstetric violence law; a lot of people are hesitant because there are many situations on paper that support the Law of Obstetric Violence that I think are quite subjective. For example... it’s happened to me before that there are patients in the delivery room and the baby’s head is outside the woman’s perineum, and she closes her legs and won’t separate them and you’re see that the baby is turning purple…and if you separate her legs and deliver the baby, she could say, ‘Ah you violated my rights, you forced me!’ So what are you supposed to do in that situation? Sit around and watch the baby die? So there’s a lot of fear now because a woman can basically call anything “obstetric violence.” In her statement, Dr. Sara describes an impossible situation. She weighs what she sees as her responsibility as a physician, ensuring a live birth, against her fear of being sued if she intervenes. In making a decision for type of birth, Dr. Sara feels that she does not solely consider medical criteria, but she must additionally factor in the potential legal consequence of the patient’s dissatisfaction with her work. Other doctors echoed Dr. Sara’s concerns, particularly that any ordinary action could be held against them under the obstetric violence law. For example, Dr. Camilla, a physician who completed her residency at Hospital General and has spent one year as a 104 ! ! senior physician at Hospital Pequeño, summarized her thoughts on legal ramifications of obstetric violence by citing a case she was familiar with. She explained, “…patients can complain about anything, sometimes without any basis, and file a lawsuit.” When I asked her for an example she elaborated, “For example, a patient stated that because she is Mayan, the doctor didn’t treat her well and disrespected her and that this was obstetric violence... so she [the patient] filed a lawsuit.” Dr. Camilla felt that doctors must take certain steps to prevent such situations from occurring, saying. “Now, what they call ‘defensive medicine’ is important to protect oneself against the accusation of the patient.” Dr. Camilla feels that she must be meticulous in her practice to prevent patients from blaming her. Dr. Camilla was not alone in expressing her view that patients might make baseless claims against physicians. Dr. Jesus, a senior physician at Hospital Pequeño with over 25 years of experience explained, “The patient can have an idea of what they think was malpractice, but they almost never have a reason.” Like Dr. Camilla, Dr. Jesus feels vulnerable believing that he can be wrongfully accused at any point during an encounter. Physicians explained that the fear of a baseless accusation led many of them to make particular decisions to avoid such an outcome. Dr. Victor, a senior physician at Hospital General, sees C-sections as an important way to avoid a negative outcome that might lead to a legal issue. He posited, “I’d rather do three or four unnecessary Csections than have something go wrong.” Similarly, Dr. Valentina, a senior physician at Hospital General emphasized that if a patient indicated that she would like a C-section at any point during the medical encounter, the patient might use legal action against the physician. She explained: 105 ! ! That law [obstetric violence] can be applied to everything. If the patient tells you “Operate on me” and you say no, since she has all the conditions for a vaginal birth… and you do a vaginal birth but some complication happens…she can sue you with that law. The doctor of today says, ‘If the patient wants a C-section, it’ll solve those problems for you,’ and they operate. In Dr. Valentina’s view, a C-section is a way to safeguard her decision against legal action. She fears that if any point a patient indicates a preference for a C-section, then the doctor may be liable if something is to go wrong. She sees a C-section as a way to “solve this problem,” and believes that she is less likely to experience any repercussions, should any complications arise during birth. The senior physicians also noted that ultimately, they bear the full responsibility of any decision made under their supervision. Dr. Joaquin acknowledged that should an adverse outcome occur, residents are not legally responsible. He explained how he sees his position, stating, “If something bad happens, you- the doctor- gets sued. They don’t sue the hospital. They don’t sue your boss… As the senior physician, if I sign off on something, and there’s any lawsuit, the patient sues me, the senior physician.” Dr. Joaquin’s recognition that he bears full legal responsibility for birth outcome additionally illuminates the importance of senior physicians making the “safest” decision for their patients’ delivery, which Dr. Valentina feels is often a C-section. Interestingly, despite the prevalence of these concerns, lawsuits against physicians working at SSA hospitals accepting Seguro Popular are nearly nonexistent in Mexico. When I asked Dr. Santiago, the administrator at Hospital General if lawsuits were an issue there, he responded, “Lawsuits aren’t a major concern here, but I suppose they’re a general concern for any practicing doctor.” I asked Dr. Santiago if in his 27 years of experience at Hospital General there had ever been a lawsuit against him or anyone he 106 ! ! knew at the hospital. He replied, “No no, nothing that has gone to court. The most we’ve had are different complaints.” Indeed, when I asked the physicians interviewed in this study if they have ever been named in a lawsuit or had a lawsuit filed against them, they unanimously responded “no.” However, as discussed in Chapter 3 with the example of the #YoSoyMedico17 campaign, there have been a handful of lawsuits in the IMSS hospital system in recent years, and physicians at Hospital Pequeño and Hospital General expressed that they feared such events would begin to occur in Seguro Popular hospitals. Senior physicians seemed to base their anxiety of lawsuits over the possibility of this occurring, and felt that C-sections helped to avoid potential blame. Unlike the hospital administrators, senior physicians did not directly tie outcome to producing a favorable statistic. Rather, to senior physicians, the more immediate consequence of a lawsuit led them to see outcome as significant, utilizing C-sections to aid in preventing a bad outcome. Medical Hierarchy and Blame: Residents’ Perceptions of Institutional Stress Like the senior physicians, residents felt that the administration viewed the hospital’s C-section with indifference. However, in contrast to senior physicians, the residents interviewed in this study had an entirely different set of concerns within their work environment, which affected birth decisions. To understand how residents make decisions, it is important to examine how they conceptualize their work setting and how they perceive their ability to make decisions. Nearly all of the residents stated that the hours that they work are the most stressful part of their job. Working 34 hour shifts every three nights, the residents work well over 100 107 ! ! hours per week. When the residents are assigned to the Toco for a rotation, they report feeling especially overworked. While residents rotating in the recovery ward or oncology unit are able to take breaks to eat lunch or sleep for a few hours on an overnight shift, residents working in the Toco work almost constantly for their entire shift. One first year resident succinctly summarized, “What don’t I like? Not being able to shower, eat, go to the bathroom or sleep.” During my observations, it was not uncommon to see a resident standing up to type up patient notes on a typewriter with one hand, and desperately trying to eat a sandwich or sip a Coca Cola with the other hand. I frequently observed residents falling asleep standing up during rounds, or nodding off the moment they sat down to type up notes. Interestingly, grades did not appear to be a source of concern to the residents, although they are assessed every few months by taking an exam that they must score a minimum of 80% on, a resident must repeatedly fail exams in order to be removed from residency. According to the administrators, residents, and senior physicians, a resident failing out of residency due to exam scores is nearly unheard of. Residents said that the only fellow residents they knew who had dropped out of their residency did so out of choice, as they decided that they no longer wanted to pursue medicine. Another component of residents’ assessment in addition to exams is an informal practical assessment of residents’ attitude and technical skills. While in theory one attending physician is in charge of the practical skills assessment, other senior physicians and senior residents also can contribute feedback. Residents noted that this informal assessment often outweighs formal examinations. Dr. Rafael elaborated on the system of assessments, saying, “Here it’s really subjective. Really, it mostly depends on the 108 ! ! perception of your superior. Honestly, [formal] exams don’t mean anything.” Dr. Gabriella, another second year resident elaborated this view, stating, “Well I think evaluations are at least half due to your attitude. They give us exams pretty sporadically… but sometimes I think that they don’t weight exams as much as our attitudes.” Rather, residents assert that relationships with other physicians and the opinions of senior physicians hold more weight for their assessments. The residents’ view of how they are assessed aligns with Frederic Hafferty’s (1994) concept of “the hidden curriculum,” subtle and insidious elements of training that shape physicians’ behaviors (403). Hafferty asserts that in order to understand the perspectives of physicians in training, researchers must look beyond the formal curriculum purportedly utilized to evaluate physicians, and instead must explore less visible interactions and dynamics, or the “hidden curriculum.” He contends that a critical component of the hidden curriculum is physician evaluation. Such assessments do not include formal learning evaluations like exams, but rather include elements like students’ relationships with other physicians, and the type of behaviors rewarded within a particular setting. Like Dr. Gabriella and Dr. Rafael note, formal examinations carry little weight in Hospital General, but rather, their relationship with their superiors bears greater importance in their assessments. Throughout my interviews, it became clear that a resident must perform their duties well to avoid poor relationships with senior physicians. During interviews, I asked each resident which responsibilities he or she maintained in that year of training. Residents’ responses were nearly identical, illustrating how clearly delineated their duties are. In the Toco, first year residents are typically responsible for admitting patients by 109 ! ! performing an initial exam and filling out that patient’s paperwork. They must also monitor the patient throughout their labor, regularly performing cervical exams to assess how far along patients are. They must also supervise the interns rotating in OB/GYN. Second year residents also help with monitoring labor, and at Hospital General, second year residents frequently perform vaginal deliveries. These residents are also responsible for checking the vitals and incision sites on women in the recovery area of the birth ward, an area where women rest immediately after labor. Second year residents rotating at Hospital Pequeño are allowed to practice their surgical skills by performing C-sections with senior physicians. Third year residents begin to regularly operate, performing the majority of the C-sections at Hospital General. Fourth year residents operate alongside third year residents, supervising their surgical technique during C-sections. They are also responsible for residents of lower levels of training, ensuring that these residents are carrying out their respective duties. Residents frequently mentioned the rigid medical hierarchy of Hospital General and Hospital Pequeño. Residents felt that this strict medical hierarchy affected their ability to make decisions. Dr. Patricia, a first year resident explained: What I don’t like the most is the hierarchy. You already know what you arefourth year residents, third year residents, second year residents- well the hierarchy is strictly demarcated. The fourth year resident is the boss- they’re the boss and what they say, we do… without taking into consideration the opinions of first and second year residents... they make the decisions, whether good or bad. Dr. Patricia’s remark that each resident “knows what you are” illuminates the importance of the hidden curriculum at Hospital General. Each resident must abide by the designated tasks for their year of training. She feels that as a first year resident, she must carry out 110 ! ! her duties without expressing her medical opinion, even if she disagrees with a “bad” decision of a superior, because it is not her place to challenge this choice. Complying with one’s position within the medical hierarchy at Hospital General was often a source of frustration for younger physicians, as first year resident, Dr. Jamie remarked, “We [as younger residents] don’t make many decisions; I think our position is pretty useless.” Dr. Patricia and Dr. Jamie feel that their thoughts do not meaningfully impact how decisions are made. They express that following the decisions of their superiors is easier, as they feel that their opinions are both unwarranted and unwanted. Dr. Patricia and Dr. Jamie’s statements are particularly illuminating in light of Chapter 4’s discussion of residents’ views on C-sections. Like Dr. Daniel and Dr. Anna stated in Chapter 4, they felt that senior physicians pushed C-sections over vaginal births before giving women an adequate opportunity for labor to progress. Although Dr. Daniel expressed frustration that senior physicians operated in the absence of a medical indication, he also felt he was unable to alter their decision. “In the end, the decision for a C-section is their [the senior physician’s] call,” he explained. While several of the residents criticized senior physicians’ eagerness to jump to performing a C-section, I never observed a resident challenging a senior physician’s decision for delivery method. Dr. Patricia and Dr. Jamie’s thoughts may lend insight as to why residents felt unable to resist senior physicians’ preference for a C-section, even in the absence of strong indications. Feeling “useless” and that their opinions are unwanted, residents may feel unable to voice their thoughts in the context of delivery decision-making. Another major factor that arose during our interviews that impacted residents’ decision-making was the fear of being punished if they did not fulfill their responsibilities 111 ! ! or made a mistake. Dr. Anna, a first year resident explained, “I really don’t like the punishments of residency. Sometimes superior residents treat you in ways that aren’t great- they’ll give us punishments like extra hours. Same with senior physicians. They’ll tell you to do more things and punish us in that way.” Dr. Anna described that other punishments entail coming in on their one day off or staying late after their shift ends. I asked Dr. Anna what kind of actions merited punishments, and she told me that at times she felt unfairly blamed for situations beyond her control: For example, they’ll punish us because an intern who was supposed to assist in a surgery arrived late, because she had a mandatory class that she couldn’t miss... and for each minute she was late, they keep us an extra hour. It’s not our fault or anything; the intern was complying with what her program requires... but she arrived late, so they punish us, the residents. Dr. Anna also described punishments for cases in which a medical error was made, such as administering incorrect treatment. She expressed that these punishments added to the stress of residency; in addition to learning how to make the correct medical decision, Dr. Anna felt that residents had to fear making a mistake. She felt that residents were consistently blamed, whether the situation is in their control or not. Dr. Juliana, a fourth year resident, felt hopeless that this system would change. Discussing punishments from superiors during our interview, Dr. Juliana sighed saying, “I don’t like it but they said it’s always been this way and it’ll always be this way.” Analyzing these residents’ comments in light of Hafferty’s (1994) concept of the hidden curriculum, we can better understand how residents’ perspectives on decisionmaking for C-sections are shaped. Residents must perform the duties designated for their level of training; failing to meet senior physicians’ standards for these tasks resulted in punishment. First and second year residents in particular were not expected to make 112 ! ! decisions for delivery method, but rather performed tasks like assessing cervical dilation and doing the intake paperwork. Transgressing these duties may result in reprimands from senior physicians or residents. As evident in Dr. Patricia and Dr. Jamie’s comments that their medical opinions are meaningless, residents’ fear of punishments may also influence their ability to make or challenge decisions. Although many of the residents recognized that not all C-sections were medically necessary and voiced criticism of the high C-section rate in our interviews, residents (particularly in their first two years) seldom questioned a senior physicians’ decision for a C-section. Residents’ perception of hierarchy and punishment may explain why they more frequently followed senior physicians’ instructions, rather than offering additional thoughts. Additionally, Hafferty contends that establishing “clinical competency” is a critical component of the hidden curriculum. Thus, an eagerness to establish surgical skills as obstetricians may also explain why residents readily performed C-sections. The residents’ perspectives on decision-making varied notably from senior physicians and administrators. Their primary concerns focused not on hospital review criteria, but on finding ways to survive the gruelling hours and rigid medical hierarchy of residency at Hospital General. Many of the residents felt that following along with superior physicians’ or senior residents’ decisions was easier than trying to express their own, as their opinions were considered unimportant. Thus, residents remained rather detached from the administration and Ministry of Health’s emphasis on data production; the residents felt more anxiety over how to endure the day-to-day pressures of residency and to avoid blame over poor outcomes. 113 ! ! Conclusion Erikson contends that through data performativity, new categories can be “made,” depending on what is counted and who is counting. The relative importance of particular metrics, like the MMR statistic, against metrics weighted less heavily, like the C-section rate, reconstructs reality for different actors involved. Dr. Valeria, as an administrator at the Yucatan Ministry of Health, sees MMR as the most important indicator assessed by the federal government, and fears consequences like loss of funding if the hospitals accepting Seguro Popular in the Yucatan produce poor statistics. This concern is reiterated among high-level administrators at Hospital General and Hospital Pequeño, as Dr. Santiago and Dr. Isabella remain aware that their jobs and hospital funding could become jeopardized by unfavorable MMR outcomes. While senior physicians and residents also focus on outcomes, they do not see the production of MMR statistics as the motivation for achieving good outcomes. Rather, senior physicians fear that a poor outcome will yield legal consequences, while residents feel compelled to follow a senior physician’s decision in order to avoid ramifications for speaking up. At each level in the system, we see that responsibility and blame are attributed in variable ways. The federal government holds the Yucatan Ministry of Health responsible for the MMR outcomes of all hospitals utilizing Seguro Popular in the state of the Yucatan. Failure to achieve the desired outcomes might result in a loss of funding. Dr. Valeria sees individual hospitals in the Yucatan as accountable, describing ramifications like firing hospital administrators if a hospital does not meet the state’s standards. Within Hospital General and Hospital Pequeño, Dr. Santiago and Dr. Isabella hold physicians at these hospitals as responsible for supporting institutional goals. Senior physicians note 114 ! ! that they will be held legally liable for poor outcomes, and thus actively try to avoid engaging in actions that might result in lawsuits. In contrast, residents perceive that they will be held accountable for not performing as directed, and try to evade blame from senior physicians. In fully examining the effects of a system so dependent on quantification and outcome, it remains critical to explore the ramifications for the party who should theoretically act as the center of the medical encounter: patients. The next chapter analyzes how this outcome driven system ultimately replicates existing structures of inequality, ultimately holding marginalized populations accountable for their own circumstances. ! ! ! ! ! ! ! ! ! ! ! ! ! ! 115 ! ! ! ! ! ! ! ! Chapter 6: Physicians’ Expectations for Patient Behavior: Blame through Microaggresions 116 ! ! During my second day in Hospital General, I was observing the bustle of the Toco when an intern tapped my arm. “Let’s go watch this birth!” she told me excitedly. As we neared the delivery room, I heard a series of loud screams that grew in intensity as we approached. Dr. Sofia, a third year resident, was delivering the baby of a 16-year-old patient. The room was incredibly crowded as two first year residents, a few second year residents, several nurses, and a handful of interns surrounded Dr. Sofia all facing the woman’s vagina. With beads of sweat trickling down her forehead, the patient moaned, “I can’t take this anymore. I really can’t do this.” Ignoring this comment, a first year resident coached the patient to breath through her mouth and to push with her next contraction. Without a word to the patient, Dr. Sofia began to perform an episiotomy, making a vaginal incision. “DOCTOR WHY ARE YOU CUTTING ME?!” the patient shrieked in pain, “PLEASE STOP!” “Ay, calm down mi hija,” Dr. Sofia responded without looking up. An intern commented to me that Dr. Sofia had injected the woman with lidocaine prior to the incision, as was standard for vaginal births at Hospital General. Several minutes later, Dr. Sofia delivered the baby. Exhausted, the patient laid silently on the bed as a first year resident began to stitch up her episiotomy. As the resident began to stitch, the interns and other residents that had come to watch the birth left the room. On our way back to the main area of the Toco, the intern commented to me, “They’re like that when they’re young… yelling, yelling yelling. When they’re older, they’re more [makes a serious face and breaths deeply]. That patient is so young, just 16. But then she shouldn’t have gotten pregnant, you know?” -Field Notes, May 14, 2014 Introduction I remember leaving Hospital General that day feeling deeply disturbed, questioning how these doctors could appear so indifferent to this patient’s suffering. Furthermore, I was struck by the intern’s comment implying this patient shouldn’t have become pregnant if she couldn’t endure this pain and treatment. My initial thought was that perhaps this situation was anomalous; maybe the physicians involved in this birth lacked empathy or were particularly harsh. Yet, I observed similar situations repeatedly throughout my three summers of fieldwork. As I came to know the physicians better, including Dr. Sofia and this intern, I found that they were far from heartless; they were genuinely kind people who truly wanted the best for their patients. Thus, I came to wonder how physicians become desensitized to patients’ pain. How do these women 117 ! ! transform from patients in pain to an annoyance to these physicians? What social, political, and economic factors shape this behavior? Finally, why are patients in this system blamed for their circumstances? To better understand the implications of changes to health care in Mexico, this chapter will explore the effects of this system on physicians’ interactions with their patients. In the last chapter, I examined the impact of institutional structure on physicians’ behavior, observing how physicians differently understand institutional demands. This chapter will build on these findings, as I will examine the effects of this system for patients, noting specific ways in which social, political, and cultural dynamics shape encounters between physicians and patients in the context of the public hospital. Ultimately, this chapter will consider how Mexico’s deep history of discrimination against low-income, indigenous groups, combined with the disenfranchising environment of the public hospital, influences physicians’ expectations and subsequent behaviors towards patients. Intersectionality as a Theoretical Framework In exploring the multiplicity of mutually interactive factors that shape physicians’ perspectives and actions towards patients, intersectionality theory provides a useful framework. Intersectionality theory contends that an individual’s “social location,” variables such as gender, race, geographic location, economic status, and culture, uniquely interact to shape an individual’s perspective and subsequent behaviors. This framework holds it is especially important for researchers to understand the interplay of these dynamics in producing a distinct experience or identity, or “the relationships among multiple dimensions and modalities of social relations and subject formations” (McCall 118 ! ! 2005: 1771). Through exploring how subjects are formed through the lens of intersectionality, we can gain a greater understanding of how particular groups or individuals become ‘othered’ or viewed as different. For example, Natalia Deeb-Sossa (2007) found that health care providers’ own class and racial background at a women’s clinic deeply impacted their understanding of the women that they cared for, viewing Latina patients as kind and in need of help while conceptualizing African America patients as ‘difficult’ (760). This framework is particularly insightful in understanding the dynamic between physicians and patients in Hospital General and Hospital Pequeño, given the complexity of social, cultural, racial, and institutional variables in this setting. This chapter will examine the factors shaping physicians’ views of patients, including a power divide between physician and patient, the institutional structure of the public hospital, and discrimination towards indigenous groups, particularly towards women. Moral Regimes and Microaggression in Childbirth An important element to consider when applying intersectionality theory is the standard of morality within a given setting. Reproduction is a particularly salient area through which these ideas can be explored, as social scientists observe centuries of attempts by governments, religious organizations, and other groups to control and regulate reproduction (Ginsburg and Rapp 1991; Leavitt 1983; Morgan and Roberts 2012). Ginsburg and Rapp (1995) contend that within a given social context, not all women are equally encouraged to reproduce. Describing this subtle but coercive pressure as “stratified reproduction,” Ginsburg and Rapp define stratified reproduction as “the power relations by which some people are empowered to nurture and reproduce, while others are disempowered” (1995:3). Through this concept, the authors assert that 119 ! ! typically the reproductive activities of dominant social group are viewed favorably, while the reproduction of other groups is considered detrimental. Morgan and Roberts (2012) build upon this idea, suggesting that a critical mechanism through which certain reproductive standards are enforced is through utilizing moral rationales, or “moral regimes.” They define moral regimes as “the privileged standards of morality that are used to govern intimate behaviors, ethical judgments, and their public manifestations” (2012:242). The authors contend that moral regimes must be examined within the specific historical context of a region, asserting that new rationalities are created for groups and individuals that are perceived to hamper the goals of the state (2012:240-244). Giving the example of reproduction among Nicaraguan immigrants in Costa Rica, Morgan and Roberts note that studies have found health care professionals to view these immigrants as “irrational reproducers,” leading to a higher rate of tubal ligation among Nicaraguan immigrants (2012: 242). Smith-Oka (2015) explores specific mechanisms through which such standards of morality are applied, finding that negative interactions between physicians and patients serve to condemn particular behaviors. She defines these interactions as “microaggressions,” describing microaggressions as “subtle insults and demeaning behavior typically aimed at people of color (or… “problematic others” in general) that reflect and enforce the perpetrators' perceptions of their superiority” (2015:10). She contends that microaggressions between physicians and patients at a public maternity hospital in Puebla, Mexico took four different forms: microinsults (callous comments based on racist or prejudiced ideas), microassaults (negative verbal or non-verbal actions), microinvalidiations (dismissing patients’ feelings or knowledge), and corporal 120 ! ! microaggressions (derogatory physical interactions). Smith-Oka posits that microaggressions are a form of reproductive governance, as certain behaviors and decisions viewed as immoral or risky are punished through microaggressions. Before I discuss how physicians at Hospital General and Hospital Pequeño create particular standards for patients, it is crucial to situate these physicians’ within Latin America’ history of race and class based discrimination. Controlling Reproduction: Responsible Family Planning in Latin America Morgan and Roberts’ (2012) concept of moral regimes is particularly salient in Mexico. They observe that in much of Latin America, the morals applied to particular groups have notably changed over time. For example, they observe that the majority of Latin America is Catholic, and Catholicism traditionally forbids the use of birth control. However, the authors note that certain groups in Latin America perceived as defiant to the progression of the state were often encouraged to utilize birth control in the last half of the 20th century (2012: 245-247). Gabriela Laveaga (2007) notes that in Mexico, such efforts largely targeted poor, indigenous individuals. She writes that public campaigns in the second half of the 20th century targeted particular behaviors seen as a hindrance to Mexico’s attempts to modernize through decreasing population growth. She observes that these campaigns often applied stereotypes to indigenous people, casting the men as overbearing and macho and women as passive and docile. Such campaigns discouraged men from “macho” behavior with slogans like, “The macho is hard and aggressive, the man knows how to understand. The macho is impulsive and violent; the man knows how to control himself” (2007:27). In contrast to the characterization of the macho as controlling and dominating, these campaigns portrayed women as weak and submissive. 121 ! ! Laveaga notes that one advertisement read, “She who is a true woman assumes responsibilities and takes decisions over her own life, her family and her reproductive activities. She who is passive fears responsibilities” (2007:25). The women in such campaigns were often dressed in traditional indigenous clothing, thereby representing this passivity. Birth control was a central topic in these portrayals, with the macho represented as forcibly pressuring the passive woman into having more children. Rural, impoverished individuals were particularly targeted in these campaigns. Laveaga notes one poster in which a woman was bent over with a child strapped to her back with a small bag of apples, reading “With such modest means, is it right to have so many children?” (2007:25). As this campaign implies, controlling reproduction became a central component of becoming a responsible, modern citizen. Individuals already living in poverty who continued to reproduce were portrayed as a drain to national resources. Such messages illustrate the concept of “stratified reproduction,” as certain groups, in this case rural, poor individuals, are discouraged from reproducing. Controlling reproduction continues to be at the forefront of Mexico’s national health agenda. From 2006-2012, the national Mexican Ministry of Health established three main goals regarding contraceptive use. These goals included increasing the use of contraceptives to 75% among women of reproductive age, to reduce the gap in contraceptive use between rural and urban populations by four percentage points, and for 70% of women to consent to a form of contraception at major obstetric hospitals during the post-partum period (Secretaría de Salud 2008). In addition to the government’s goal of lowering reproduction rates, physicians at Hospital General and Hospital Pequeño 122 ! ! expressed the opinion that their patients excessively reproduced. “We have people here without very much culture:” Women as Uncontrollable Reproducers Physicians at Hospital General and Hospital Pequeño often described indigenous women as passive, particularly in the realm of family planning. This belief is poignantly illustrated in an interaction I had with Dr. Sofia, the third year resident referenced in the vignette that opened this chapter. One day in the Toco in July 2015, I had asked Dr. Sofia a few questions about the patient population she works with. A couple of hours after our conversation, she approached me and asked if I was using photos in my study. I told her that that I might be using some pictures, without names or identifying information. “Well, I’ve got something for you then,” she responded. Dr. Sofia pulled up a picture on her phone of a consent form for a tubal ligation procedure. There was a line on the form that asked for the reason that the patient declined. A patient had written in this spot “Because I believe in Jesus Christ.” Dr. Sofia laughed, “This is what I was explaining to you earlier,” she said. She told me that she had another picture she wanted to show me but couldn’t find on her phone, in which a woman also declined a tubal ligation with the explanation, “Because my husband takes care of me.” “There’s so much machismo here,” Dr. Sofia sighed. Dr. Sofia saw these responses as being ridiculous to the point of comical; she felt these women justified their decisions with utterly irrational reasons. Dr. Sofia’s characterization of patients as uneducated and unwilling to stop reproducing was echoed in other physicians’ statements. When I asked Dr. Patricia, a first year resident, if she felt that there were any special characteristics about the patient population at Hospital General that influenced the care she gives, she responded: 123 ! ! When they speak Mayan it’s really difficult because we can’t communicate with them. But also, we can’t convince them to plan for their families… they have a false idea about what a tubal ligation is- they never want one. They’d prefer to have eight kids because they feel [getting a tubal ligation] is something bad. Similar to Laveaga’s (2007) discussion of the characterization of indigenous women as rampant reproducers, Dr. Patricia feels that Mayan-speaking women are inexplicably adverse to certain forms of contraception, instead preferring to continue to reproduce. As Morgan and Roberts noted, a moral regime is often apparent in understanding how reproductive behavior is regarded, as these moral standards frame certain behaviors as wrong or irresponsible. We can see the presence of a moral regime in Dr. Patricia’s remark, as she sees certain patients as ignorant and irrational. Interestingly, Dr. Patricia does not feel that all patients are unable to control their reproduction; she specifically connects this characteristic to patients who are Mayan speaking. Thus, she creates a different standard for these patients, viewing a tubal ligation is an appropriate option for this population, preferable to continuing to have a large number of children. Similar to Dr. Patricia’s comment, several of the physicians responded to my question about special characteristics of the patient population by describing patients as having a “low level of culture.” When I asked to clarify what a low level of culture meant, the response often involved the lack of family planning due to erroneous beliefs or lack of ambition. This idea is particularly salient in my interview with Dr. Isabella, an administrator at Hospital Pequeño who we met in Chapter 5. When I asked Dr. Isabella if there are any characteristics about the patient population here that affect the type of care that she’s able to give, she responded, “The first thing is, we have people here without very much culture… I think that's… one of the big limitations here.” I then asked Dr. 124 ! ! Isabella if she could explain to me what “people without very much culture” meant. She elaborated: It means that 90% of women here who are pregnant didn’t plan it…. It’s not like other countries where first I assess my situation and say, ‘I’m ready now’ or ‘I’m in the best situation to procreate.’ The woman from here- no. There’s no empowerment with these women; that’s also why there’s a short period in between pregnancies here. Because they don’t evaluate. There are no individual goals for a woman. Here, we’re continuing to live within a culture where the more children a woman has, the more of a woman she is. She forgets about herself… and also the name of her oldest child who’s taking care of her youngest, child number 13. Dr. Isabella’s statement reiterates Laveaga’s discussion of racial stereotypes of indigenous individuals in Mexico; Dr. Isabella sees patients as fundamentally different culturally, perceiving them to passively continue to reproduce without goals. Her remark is imbued with moral rationales. She sees patients’ lack of planning and assessment of their situations as irresponsible. Although she uses the tense of nosotros (we) in her statement, she sees herself as battling this ideology, thereby drawing a clear distinction between herself and these women. Implicit in her statement is her view that continuing to reproduce is detrimental for women that won’t be able to care for the large number of children she presumes that they will have. Discipline for Excessive Reproduction In addition to physicians expressing criticism towards women who they judged to be acting passively by not controlling their reproduction, during physicians’ interactions with patients, I observed that physicians continually emphasized the importance of contraceptives to patients. When patients did not readily agree to contraceptive use, physicians utilized a number of microaggressions in their attempts to persuade women to use birth control. 125 ! ! Typically, a conversation regarding contraceptive use occurred after women gave birth. At Hospital General, patients were usually asked at least twice what contraceptive they plan on using (Con que te vas a cuidar?). Immediately after birth at Hospital General, women were wheeled into a room in the back of the Toco, where they rested for several hours until space freed up on the second floor recovery room. Interns and residents that had worked the night shift the previous evening were responsible for caring for these patients. This room was generally tranquil compared to the rest of the Toco; anywhere from six to thirteen women quietly rested on beds several inches from each other in this dimly lit room. A group of four to seven interns and residents rounded on patients once in the morning and once in the afternoon. An intern typically lugged a large notebook along during rounds, carefully jotting down each patient’s vitals. During rounds, residents examined the vitals taken by the intern, checked the stitches if that patient had a C-section, and again asked what contraceptive that patient planned to use after she left the hospital. Physicians yet again asked this question in the recovery ward on the second floor during rounds. As the recovery ward was generally a slower paced environment than the Toco, physicians typically spent a few minutes longer discussing contraception with patients. Hospital Pequeño differed from Hospital General in the way patients were asked about family planning. Rather than interns and residents inquiring as to contraceptive use, a physician, Dr. Fabiola, a general practitioner at Hospital Pequeño, works solely in family planning. This family planning program was established in Hospital Pequeño in 2016 in an effort to reach the national guidelines for contraceptive use. I shadowed Dr. Fabiola on her rounds with patients in the morning and evening. Dr. Fabiola carried 126 ! ! around a large cardboard poster, with various contraceptive items taped to it. She spent an average five minutes talking with each patient about contraceptive options, whereas in Hospital General, residents and senior physicians discussed contraception for approximately one minute. When Dr. Fabiola was not rounding, she worked in a room labeled “Family Planning,” performing consultations with women about IUDs, birth control pills, and tubal ligations. Dr. Fabiola’s office contained multiple information packets made by the Mexican Ministry of Health for women regarding more information about contraceptives. These packets were often oversimplified and infantilizing; for example, the cover of one contraceptive information pamphlet entailed a cartoon drawing of condoms as French fries with smiling faces, next to a burger and a Coca Cola. I learned quickly during observations in both settings that “none” was not an acceptable answer to the question Con que te vas a cuidar? (What kind of birth control will you use?). Patients classified as “high risk,” most commonly due to young age, preexisting medical condition, adverse medical event during pregnancy or delivery, or a high number of pregnancies, were typically subject to additional scrutiny by physicians. Women who refused birth control were especially pressured by physicians to accept contraception. While physicians typically pointed to some form of medical risk as their initial reason for emphasizing contraception, ideas of patients as socially and economically risky often arose throughout the conversation. In the next section of this chapter, I will present an example of an encounter that I observed on the recovery floor of Hospital General to illustrate this idea. Microaggressions and Birth Control Use: “If I were you I’d never get pregnant again” The following vignette taken from my field notes from August 2016, describing 127 ! ! my observations during patient rounds: Dr. Juliana was leading rounds as the physicians examined an 18-year-old patient who had given birth to her first child the night before. I was told by an intern that this patient currently has high blood pressure and had a small seizure during labor. Draped in an oversized orange hospital gown, and looking far younger than 18 years, the patient appears to be bored in the recovery room; after all, there are no TVs, magazines, or books for patients to read during their stay. She looks down as the group of physicians arrives at her bedside, chipping away at her partially painted nails. “You had a really serious situation last night,” Dr. Juliana tells her, “What are you going to use for contraception?” The patient continues to look down and does not respond. “Listen, if I were you, I would never get pregnant again,” Dr. Juliana remarks, rubbing her own pregnant belly. “You’re high risk and you had a really serious situation. Women with your condition die. I would wait at least 5 years to get pregnant again,” she continues. The patient still does not look up or respond. Dr. Juliana tells her that they will decrease her dosage of hypertension medications over the next day, and reassess if she is able to leave the hospital tomorrow. The following day, I join Dr. Juliana and the residents on rounds. When we near her bed, the 18 year old patient eagerly looks up at the group of physicians and asks in a hopeful tone “Can I leave yet?” Dr. Juliana asks her who is caring for her baby while she is in the hospital. “My husband,” the patient replies. “And what about when your husband goes back to work?” Dr. Juliana asks. “My mother-in-law will watch her then,” the patient answers. “What will your mother in law and husband do if you have another seizure?” asked Dr. Juliana. Dr. Valentina interjects, “Your baby is going to want a healthy mother.” “It was because of the pregnancy,” the patient murmured. Dr. Juliana and Dr. Valentina fervently exclaim in unison. “NOOOO!” Dr. Valentina asserts, “It was because you had hypertension and THEN got pregnant. If you sign a paper to leave the hospital against our advice and get sick again, Seguro Popular [the public health insurance] won’t cover it. Do you know how much that costs? It’s 20,000 pesos a night.” The patient remains silent and looks down at her hands. “If you won’t think of yourself then at least think of your baby,” Dr. Valentina scolds. We move on to the next bed. The next day, I am present again as the physicians examine this patient. The physicians have determined that this patient will be able to leave today. Dr. Juliana holds up two bottles of medication to the patient. “Okay we’re going to send you home with these two medications. You have to return in a week. It’s your responsibility. You are responsible for your own health.” Dr. Juliana continues, switching to the subject of contraception. “What are you going to use for birth control?” she asks. “You can’t get pregnant for at least 3 years.” The patient looks away from Dr. Juliana, remaining silent. 128 ! ! Dr. Juliana carries on, “We can give you injections but the intrauterine device (IUD) would be ideal. The IUD lasts for 5 years and you get it checked every year at your local clinic to make sure it’s in place. Or we can do injections every two months.” She bends down to the patient and says, “It’s really important that you do so because you’re high risk and this could happen in your future pregnancies. You’re so young; you have to plan well.” Dr. Jimena, a first year resident, sits on the edge of the patient’s bed and begins to talk to the patient about birth control. Several minutes later, Dr. Jimena says to the patient, “Ok, repeat back to me what I said and why it’s important.” The patient repeats Dr. Jimena’s statement about contraceptives, “I will receive injects for two months and then receive an IUD.” Dr. Jimena nods approvingly. “Injections it is,” Dr. Jimena announces triumphantly. In this example, we can see several instances of “microaggression” as described by Smith Oka. There are microinsults through Dr. Juliana and Dr. Valentina’s interaction with this patient. During this patient’s first day in recovery, Dr. Juliana makes the assumption that this patient will want to become pregnant again quickly, and scolds her for being so irresponsible. Later, Dr. Valentina describes a scary scenario to this patient in which she could be hospitalized for days, making the assumption that 20,000 pesos would be unimaginably expensive for this patient. Additionally, Dr. Valentina’s reprimand that this patient should at least think of her baby implicates a standard of “good motherhood” for this patient; putting her baby above herself. During one of the few occasions that this patient spoke back to the physicians regarding her medical condition (her hypertension), Dr. Valentina and Dr. Juliana immediately invalidated her comment that the pregnancy was responsible for her seizure. Viewing these physicians’ behavior through the lens of intersectionality, we can see a multiplicity of factors that interact to shape physicians’ actions. First, it is critical to consider Mexico’s history of stratified reproduction, characterizing indigenous women as incapable of controlling their reproduction. These stereotypes are clear throughout physicians’ statements, such as Dr. Patricia and Dr. Isabella’s remarks expressing 129 ! ! disbelief that patients did not regularly utilize birth control. It is also important to consider these physicians’ positions as middle class physicians in these encounters. For example, Dr. Valentina and Dr. Juliana are both from urban, middle class families. Dr. Valentina was born and raised in Mexico City, working here for several years before relocating to Merida. Dr. Juliana is from a large city in Southern Mexico; her mother is an architect and her father is an engineer. Thus, the middle-class upbringing and lifestyle of these physicians may contribute to these physicians’ moral regimes, viewing patients who resist contraceptives as acting irrationally and as acting contrary to their own wellbeing. Additionally, as discussed in Chapter 2, an inherent power divide exists between physicians and patients, as physicians hold the “authoritative knowledge” considered valuable in a clinical encounter. This inequality in power also aids in illuminating why Dr. Valentina and Dr. Juliana emphasize contraceptive use, and the patient’s inability to refuse. Finally, as discussed in Chapter 4, the stress experienced by physicians in the public hospital system, facing a large volume of patients with limited resources, also may contribute to physicians’ views. Overworked and underpaid, physicians may place blame on patients rather than the social, political, and economic hierarchies that structure the public hospital system. Within the context of the public hospital, these factors intersect, resulting in microaggresions towards women they perceive to be acting irresponsibly by declining contraceptives. Race, class, education, and work environment all mutually interact to produce the clinical encounter with Dr. Valentina and Dr. Juliana I described above, harshly reprimanding a patient for acting negligent towards her health. 130 ! ! Cooperation: Physicians’ Expectations for Patients during Labor and Delivery In addition to the use of birth control, physicians also valorized “cooperation” as an important behavior for patients. Through physicians’ explanations in our interviews and my observations, several features of the “cooperative” patient emerged, particularly accepting the pain of labor and adhering to the instructions of biomedical providers. Physicians’ expectations for cooperation created a double bind for women. As I discussed in the above section, physicians harshly criticized women they perceived to be resisting using contraceptives, feeling that patients should be morally obligated to responsibly control their reproduction. However, this standard changed in the context of labor, as remaining passive and “cooperative” during labor is an important element of reproductive governance. Accepting the Pain of Childbirth One important characteristic of the cooperative patient is the acceptance that childbirth is a painful process. This is clearly illustrated in a statement from Dr. Joaquin, a senior physician at Hospital General, about patients’ cooperation during labor. He explained what the term “cooperating” meant to him: Cooperating… it’s being prepared for having a vaginal birth. It’s a woman who wants to have a vaginal birth and knows [how a vaginal birth is]. [She thinks] “I know it hurts, I know it evolves slowly.” These women accept it. On the other hand, women that don’t want or understand how a vaginal birth is- well at the first bit of pain, they think “Ok, operate on me already, my life is at risk…” But more than anything, they think this way because a neighbor or someone told them that. Dr. Joaquin sees the cooperative patient as one who is well informed regarding the process of labor. In his opinion, such a patient will embrace the pain and longevity of childbirth; she won’t request a C-section to avoid this discomfort. 131 ! ! Patients who physicians perceived to handle the pain well were viewed favorably. One day during August 2016, I was observing Dr. Gloria, a senior physician at Hospital Pequeño, perform prenatal consults in Hospital Pequeño with an intern. A long line of women waited outside of the tiny consult room. A nurse would yell the name of a patient in the hallway, and that patient would head back to the consultation room, change from her clothes to a paper gown, and lie on the one bed in the consultation room. Dr. Gloria told me that these consults were intended for women who were past 30 weeks of pregnancy. These exams usually consisted of a few questions regarding the patient’s health history, followed by an intern measuring the woman’s pregnant belly, listening to the fetal heartbeat, and performing a vaginal exam. These vaginal exams, referred to as a tacto in Spanish, were often quite painful, and involved a physician inserting several fingers in a woman’s vagina to assess her cervix. I joined Dr. Gloria and an intern towards the end of their consults for the day. A 16 year-old girl who was 35 weeks pregnant arrived for her exam. She answered the intern’s questions and proceeded to lie on the exam table. As Dr. Gloria performed a vaginal exam, she commented that the patient still maintained a closed cervix and likely wouldn’t go into labor for a few weeks. “You’re done?” asked the patient in surprise. Dr. Gloria smiled at the patient. “Yes we are,” she responded. She turned to the intern, “She tolerates pain really well, doesn’t she? She’s not like that last patient.” I later asked the intern what the last patient was like. “Oh, she didn’t handle the [vaginal] exam very well. She was screaming and all,” she explained. Dr. Gloria’s comparison of the two patients makes it clear that she valorizes the first patient’s pain threshold. Morgan and Roberts write that within reproductive 132 ! ! governance, moral regimes are applied by being “evaluated in relation to one another, supposedly immoral and irrational activities” (2012: 242). Dr. Gloria makes a direct juxtaposition of these patients’ characteristics in relation to one another; she sees a patient that expresses pain as difficult and a patient that accepts the exam in silence as laudable. Physicians’ emphasis on tolerating pain was particularly apparent in observations during labor and delivery, as patients who did not behave according to this standard were subject to microaggressions from physicians. The Uncooperative Patient: Microaggressions Towards “Disruptive” Patients During my observations in Toco, it immediately became clear to me that patients who did not “accept” the pain of childbirth, and engaged in behavior like screaming or attempting to get out of their beds, were reprimanded. Discipline for such behavior often materialized in the form of microaggressions. Physicians frequently issued microinsults to uncooperative patients, accusing screaming patients of “stealing” oxygen from their babies, or causing distress to their child. Corporal microaggressions in the form of additional technologic intervention was another way in which patients that did not accept the pain of childbirth were disciplined. The following vignette, an observation from August 2015, illustrates how such microaggressions are applied: A 16-year-old girl in labor with her first child clutches the handlebars of her bed as she shrieks in pain, “AHHH THIS HURTS!!” She is incredibly small, weighing maybe about 100 pounds even with her pregnancy at term. She kicks her legs with each contraction, screaming in agony. The residents working in the Toco do not acknowledge this patient for at least 10 minutes. Each time she screams, I notice that they exchange annoyed glances with each other. After several minutes of screaming, a first year resident, Dr. Luis, walks over to her bedside. “When you scream, the air doesn’t get into your body well. This is what labor is like. Breath deeply.” This patient responded to Dr. Luis by shrieking, “I CAN’T DO IT ANYMORE! THIS HURTS!” Dr. Luis responds calmly, “Yes, you can. Everyone does it.” Another first year resident, Dr. Pilar chimes in, “Don’t cry and don’t scream… you’re only going to feel more pain.” 133 ! ! The patient continues to scream and thrash her body in pain. After about 30 minutes, a first year resident, Dr. Andrea walks over to the patient and sits on her bed, instructing her to take slow deep breathes with each contraction. A third year resident, Dr. Juan, listened to Dr. Andrea’s instructions, and expressed frustration that he felt that Dr. Andrea was not teaching the patient sufficiently, “Come on, really teach her,” he remarks to Dr. Andrea. He steps next to the patient. “Um, okay look Mariana,” he says to the patient. “I know you’re in a mountain of pain. You need to breath deeply so your baby gets oxygen.” Mariana looks at Dr. Juan with tears in her eyes and asks, “How much longer?” He responds, “Well it depends if you cooperate. The pain isn’t going anywhere.” Dr. Juan stands up and makes a comment to a fourth year resident that I couldn’t hear. He turns to the patient and states, “We’re going to give you something for your pain.” The interns begin to prep the patient to receive an epidural. I had never seen a patient who was delivering vaginally receive an epidural at this hospital, so I asked one of the interns why this patient was receiving one. “She has hypertension,” the intern explained. “She might raise her blood pressure by screaming.” This vignette illustrates the importance of cooperating by accepting the pain involved with labor. Several instances of microaggression are apparent in this example. Dr. Pilar issues a microinsult in her comment “you’re only going to make the pain worse,” implicating that Mariana is causing herself more pain because of her disruptive behavior. Additionally, Dr. Juan’s comment that Mariana needs to breath deeply so her baby receives oxygen implies that her current behavior is harming her child. Ultimately, Mariana is punished through a corporal microaggression in the physicians’ decision to administer an epidural to her. Physicians seem to feel that they need to manage Mariana’s uncooperative behavior through increased intervention. They assert that she is increasing her risk through her screaming, and that medication is the only means to manage her actions. Examining Mariana’s clinical encounter through intersectionality theory, several distinct variables interact to shape her experience. First, it is critical to explore how the physical space of the Toco influences Dr. Juan and Dr. Pilar’s interactions with Mariana. 134 ! ! Physicians acted ambivalently towards Mariana’s pain until it began to interfere with their work environment. They addressed Mariana once her screams were impossible to ignore. As I described in Chapter 3, the Toco is incredibly limited in space. Up to 10 laboring women can be crowded into the small pre-delivery room of the Toco, lying in beds several inches from each other. Several interns and residents crowd the room; inching between beds to examine patients or to place their typewriter on a small table typing progress notes as they stand. The screams of patients are overwhelming in this tight space. Although these physicians acknowledged that labor is a painful process, the spatial limitations of the Toco posed a challenge for the physicians attempting to tend to the labor of multiple patients. It seems that the physical constraints of the Toco exacerbated physicians’ stress, amplifying microaggressions towards patients like Mariana. Additionally, it is important to examine how physicians’ chaotic work setting may influence their perspectives, diminishing their compassion towards patients. A central component of physician “burn out” is a loss of empathy towards patients; physicians working long hours in stressful work environments are more prone to burn out (Hojat, et al. 2009; Krasner, et al. 2009; Passalacqua and Segrin 2012). Many of the physicians involved in Mariana’s case appear to be desensitized to her suffering. For example, Dr. Luis’ comment that “everyone does it” illustrates, physicians at Hospital General view pain as an inevitable part of labor. Dr. Pilar additionally dismisses the patient’s discomfort, telling Mariana that refusing to accept this pain will only result in more suffering. Tending to dozens of laboring women each day, these physicians become 135 ! ! emotionally numb towards the experience of childbirth, viewing pain as an unavoidable element of labor. Finally, analyzing this interaction in light of Laveaga’s (2007) discussion of class and race, we must consider how physicians’ view of this patient population may influence their interactions with Mariana. As discussed earlier in this chapter, a number of physicians characterized patients as rampant reproducers, incapable of making the “responsible” decision to use birth control. It is critical to consider how these beliefs may shape physicians’ moral regimes. In the case of Mariana, the comments of Dr. Luis and Dr. Pilar reflect the belief that women are choosing this pain by virtue of getting pregnant. In their view, physical suffering is tied to labor, and women should readily accept this reality during childbirth. Women who do not embrace this pain are viewed are non-compliant and irrational, resulting in physicians’ microaggressions towards patients. The physical space of the birth ward, physicians’ demanding work environment, and their beliefs about this patient population all interact to shape their encounter with Mariana, ultimately resulting in a series of microaggressions. In both the example of Mariana and Dr. Juliana’s 18-year-old patient, these factors uniquely intersect to produce distinct experiences. Through examining these encounters, we can better understand physicians’ moral regimes that underlie different elements of childbirth, helping us to comprehend why physicians’ expectations for cooperation stand in direct contrast to their disvaluing of passivity in the context of birth control. Under these moral regimes, birth control was seen as a critical part of acting as a responsible, informed patient. In contrast, the moral standard applied to labor required women to act composed and to accept 136 ! ! physicians’ directions. As the case of Mariana illustrates, reproductive governance was asserted through managing her disruptive behavior with microaggressions. Vertical and Horizontal C-section Scars: Inscribing Risk In addition to examining physicians’ derogatory responses to particular behaviors, it is intriguing to explore how physicians’ beliefs about patients may result in different management of bodies and the implications of this treatment. Social scientists contend that through exploring individuals’ physical state, such as the way in which a body is marked or a certain disease, and how this condition is conceptualized within a given setting, we are better able to understand how particular identities are produced within larger cultural, political, and social hierarchies (Davis 2003; Edmonds 2007; Farmer, et al. 2004). For example, Briggs (2003) explores the cholera epidemic in 20th century Peru, noting that the medical and political dialogue surrounding this disease create a new type of subject: the “unsanitary citizen.” He writes that characterizing individuals as unsanitary citizens carried assumptions of particular behaviors, like not knowing when to seek formal medical care and practicing unhygienic habits (2003:33-35). Elizabeth Roberts (2012) contends that examining how bodies are physically marked is critical also to understanding larger social and political dynamics. She found that the presence of Csection scars in Ecuador serve as a form of racial “whitening,” as these scars indicated that women maintained a high enough socioeconomic status to exempt themselves from vaginal birth in public hospitals (2012: 216). Roberts asserts that by changing one’s “material reality” through a C-section incision, women also can alter their social identity, representing an elevated socioeconomic status (2012:217). 137 ! ! Building on the work of Roberts (2012) and Briggs (2003), this section of the chapter will explore how a new subject is created from the physical management of patients, analyzing how a particular type of C-section incision represents broader social and racial characterizations of patients at Hospital General and Hospital Pequeño. Conceptualizing vertical C-section incisions as corporal microaggressions, I will explore the economic, political, and cultural factors that result in some women receiving vertical incisions, while others are given horizontal incisions. “They might not bathe for a week:” Physician Perspective of C-section Incisions When I first began fieldwork at Hospital General and Hospital Pequeño, I was surprised to see that physicians primarily utilized a largely outdated technique to make a skin incision for a C-section. I noticed that physicians almost exclusively made a vertical incision down the middle of the abdomen for a C-section, which is mostly used in contemporary obstetrics as an emergency procedure. Typically, a horizontal incision is made across the abdomen as the entrance for the C-section procedure. A number of reasons exist in the medical literature as to why the horizontal incision is preferred, including fewer post operative infections, less postoperative pain, and a scar that is more easily hidden, as it is lower on the abdomen (Hendrix, et al. 2000; Hetzel, et al. 1979). Thus, I was curious as to why the vertical incision was overwhelmingly more frequently utilized by physicians at Hospital General and Hospital Pequeño. As I began to explore why physicians at these hospitals utilize the vertical incision, it became clear that the use of various incisions was due less to medical factors than they were to social and cultural dynamics. 138 ! ! I asked seven of the physicians interviewed in this study about C-section incisions and two physicians specifically mentioned C-section incisions to me during observation. Of these nine physicians that discussed C-section incisions, they gave three primary justifications for performing vertical incisions more frequently than the horizontal incision. All of the physicians gave more than one reason for performing the vertical incision, including a lower technical ability, increased speed, and characteristics of the patient population. A commonly mentioned reason for the frequency of vertical incisions was that they are quicker, as five of the physicians listed time as an explanation for vertical incisions. However, physicians’ estimations of how much quicker C-sections with a vertical incision are over a horizontal incision widely varied. Dr. Jesus estimated that a Csection performed with a horizontal incision would take approximately 15 minutes longer, while Dr. Valentina felt that it would be around 4-5 minutes longer. In comparison, a study by Wylie et al (2010) found that the average time difference between vertical incisions and the horizontal was 1-2 minutes, depending on if the woman had previous C-sections. In this explanation, physicians frequently referenced the use of the vertical incision as an emergency procedure. Dr. Isabella explained, “You have to be careful with [the horizontal]; there’s more vascularity involved. If you’re not very highly trained, it’ll take more time, and if there’s a risk of dying, you can’t be taking over 20 minutes.” Dr. Isabella feels that the horizontal incision is a more complex procedure, and that this additional time could endanger the life of the mother and child. However, Dr. Isabella estimates that 90% of C-section incisions at Hospital Pequeño, a hospital that theoretically only performs non-emergent deliveries, are vertical incisions. 139 ! ! Two of the physicians interviewed explained that lower technical ability was one of the reasons that vertical incisions were more frequently performed in Hospital General and Hospital Pequeño. “Here it’s mostly residents operating with other residents,” Dr. Valentina explained, “The vertical incision requires less technical skill since you don’t have to cut through the abdominal muscles.” She noted that since many residents primarily learn how to perform a vertical incision during residency, they maintain this practice as senior physicians. Interestingly, although Dr. Valentina felt that residents continue to use the vertical incision throughout their medical training, senior physicians who also worked at ISSSTE or a private hospital said they perform both types of incisions. Most of the physicians estimated that approximately between 85- 90% of C-sections at Hospital General and Hospital Pequeño utilized the vertical incision. This estimate aligns with my observations, as I saw four horizontal incisions occur over the course of three field seasons in Hospital General and Hospital Pequeño. In contrast, physicians also working at IMSS, ISSSTE or a private hospital noted that the majority of C-section incisions at those hospitals are horizontal. Dr. Jesus stated that he believes that about 90% of incisions at Hospital Pequeño are vertical incisions, which contrasts sharply with his experiences in IMSS and ISSSTE. He explained: It’s really different. In IMSS, the population has greater resources, and [the horizontal incision] is a little more common. They can understand you a little better. In ISSSTE, about 90% of the C-sections are horizontal. It doesn’t cost extra but the patient’s understanding is better. Dr. Jesus acknowledges the wide discrepancy in types of C-section incisions between Hospital Pequeño and Hospital General and private hospitals. He felt that this difference is due to the “greater resources” of patients utilizing other forms of insurance, and 140 ! ! connects this idea to his statement that these patients are able to understand better. His statement contrasts with that of Dr. Valentina, as she felt that vertical C-sections are performed more frequently because residents at public hospitals are trained primarily to perform them. Many physicians reiterated Dr. Jesus’ sentiment that characteristics of patients at public hospitals necessitated a vertical incision over a horizontal incision. All of the physicians that discussed reasons for vertical C-section incisions referenced some trait of the patient population as a justification for performing a vertical C-section. Some of the physicians described physical characteristics of the patients as the reason that a vertical incision was necessary. Dr. Santiago’s responded to my questions of why vertical incisions are performed over the horizontal stating: Generally- well you’ve probably realized this- most of are patients are a little bit fat. Actually, really fat. So really, with the type of population we work with and the areas that they live in- well let’s say that it’s healthier to do it this way [the vertical incision]. A horizontal incision tends to fall below a fold of fat. So with the heat, being um…poor, living in locations with little water and life necessities, it’s more likely that [the horizontal incision] will tend to soften the stitches. Dr. Sebastian characterizes patients both physically and behaviorally in his description. He does not see obesity alone as an indication for a vertical C-section, but rather he assumes that obese patients in this hospital also live in poverty, and will not have the resources or capacity to adequately care for their wound. He sees the combination of these physical and behavioral traits to increase risk, thereby necessitating a vertical incision. Nearly all of the physicians included an allusion to their perception of patients’ behaviors and socioeconomic status in their description of why a vertical C-section is required. In contrast to Dr. Santiago, Dr. Isabella felt that instead of limited resources to 141 ! ! care for incisions, the patient population at Hospital General and Hospital Pequeño lacked the capacity to understand wound care. When I asked her why vertical incisions were performed more frequently, she responded, “For the cultural level of the patients… it’s not always understood when you try to tell them to identify if a wound is red, hot, or other facts [about infection].” Dr. Isabella felt that patients would be unable to correctly identify an infection, yet did not explain why this rationale meant that vertical incisions should be performed in place of the horizontal. Other physicians felt that patients possessed particular cultural nuances that led to increased infection, such as a fear or aversion to bathing. Dr. Gloria explained, “There are patients here, for example, from rural communities and you send them to their homes and when they get back there, they never wash the wound because it scares them. We have a higher risk of infection [with incisions].” Other physicians echoed Dr. Gloria’s concern that patients’ hygiene might contribute to wound infection for horizontal incisions. Dr. Victor explained, “Sometimes women here don’t bathe for a week, so they might get infected.” Dr. Victor also did not explain why he believes that women do not bathe, yet this assumption underlies his contention that vertical C-sections are necessary. Dr. Camila, a senior physician at Hospital Pequeño, also felt that patients’ behavior contributed to a vertical incision being a safer option than a horizontal, yet felt this was due to patients’ promiscuous behavior rather than an aversion to bathing. She explained, “The majority of women here don’t use any family planning and have very short amounts of time in between births, so doing a horizontal a second time would be more difficult.” Dr. Camila feels that patients at Hospital Pequeño are unable to space out their pregnancies, and that performing a horizontal incision during a C-section would 142 ! ! only serve to create more difficulty for physicians when patients inevitably became pregnant again. Vertical C-section Incisions as Corporeal Microaggressions Physicians’ justifications for performing a vertical incision over a horizontal incision conflicts with the previously mentioned medical literature. While the medical literature confirms that vertical incisions are marginally faster, it seems unlikely that 90% of pregnancies at both hospitals are so urgent that they require this type of incision. Furthermore, the medical literature has noted that vertical C-section incisions are most helpful in cases of extreme obesity, not simply overweight patients. The majority of vertical C-section incisions that I observed were not performed on obese patients, but rather, patients were a normal weight or overweight. Furthermore, several studies have found no significant difference in infection rate between vertical and horizontal incisions (Hetzel, et al. 1979; Wylie, et al. 2010). The overwhelming majority of physicians mentioned some form of patient characteristics in their responses, indicating that beliefs about this population are tied to which type of incision is performed. It is interesting to observe that in contrast to the earlier examples of microaggression that were in response to a particular behavior, the microaggression of a vertical C-section incision was in response to patient characteristics, or physicians’ perceptions of their characteristics. In both cases, Smith-Oka notes that microaggressions are not simply a result of individuals’ beliefs, but rather the expression of larger social and cultural prejudices, ultimately “exacerbating existing structures and hierarchies” (2015:9). She argues that microaggresions are perpetuated by Mexico’s deep history of classism and racism towards indigenous groups and also the stresses that physicians face 143 ! ! working in Mexico’s underfunded public health care system. Similarly, I consider that the use of vertical incisions over the horizontal incision is not simply a reflection of physicians’ personal views of the population, but instead serves as a physical representation of larger cultural beliefs regarding race, class, and reproduction. Indeed, many of the physicians’ responses reflected larger issues of classism and racism, as most of the physicians’ explanations as to why vertical incisions are more common in public hospitals reflected their views of patients as ignorant and uneducated Viewing these findings in light of the work of Roberts (2012) and Briggs (2003), we can understand C-section incisions as not only a response to larger cultural beliefs, but as a mechanism to create a particular subject. Similar to Roberts’ contention that a horizontal C-section scar “whitened” women as compared to vaginal birth, I also found that the physical alteration of women’s bodies through a vertical C-section serves as a representation of broader social and political hierarchies. Rather than a certain state of disease creating a new type of subject, I argue that the physical mark of a vertical Csection embodies particular behavioral assumptions about women at these hospitals, reinforcing impoverished women’s status as risky, uneducated reproducers. Throughout physicians’ comments regarding vertical C-sections, racialized stereotypes about these women are reinforced. Dr. Isabella feels that patients do not have a comprehensive enough understanding to properly care for a wound. Dr. Camilla’s thought that patients become pregnant again too quickly aligns with the earlier discussion in this chapter of indigenous women as uncontrollable reproducers. Other physicians, like Dr. Victor and Dr. Gloria, expressed racist assumptions about patients, asserting that patients do not shower or utilize proper hygiene. Interestingly, neither reported experiencing a high 144 ! ! volume of patients returning to the hospital for wound infection. These physicians see these women as too risky to receive the horizontal incision due to behaviors and beliefs that they assume these patients possess. It is important to note that rather than shifting blame towards larger social, political, and economic structures that may result in women not receiving adequate nutrition or hygiene, these physicians primarily place the blame for these actions on their patients. Thus, a vertical C-section incision carries along behavioral implications: women with a vertical C-section incision are irresponsible, unhygienic, and prone to excessively reproduce. Analyzing physicians’ perspectives on C-section incision in public versus private hospitals particularly illuminates how the presence of a C-section incision marks social identity. All of the physicians acknowledged that vertical incisions are performed far more frequently at Hospital General and Hospital Pequeño rather than at IMSS, ISSSTE, and private practice. Dr. Jesus describes the women in these hospital systems as maintaining “better understanding” because of their elevated socioeconomic status, enhancing their ability to adhere to biomedical practices. The patient population at public hospitals is seen as unworthy of receiving an incision that is more aesthetic, and instead is marked by scar central on their abdomens. As such, the presence of a centrally visible vertical scar on their abdomens represents a lack of education and resources, while a horizontal C-section incision reflects a responsible and well-informed citizen. Finally, it is also critical to consider the way in which the institutional context of the public hospital influenced physicians’ opinions about patients’ characteristics. Smith Oka (2015) noted that the chaotic, underfunded public hospital system increased physicians’ stress, leading to intensified microaggressions. I also found that the brutal 145 ! ! work environment of the public hospital system seems to exacerbate physicians’ existing prejudices about the patient population. While physicians’ characterized women at Hospital General and Hospital Pequeño in negative terms, several of the physicians expressed empathy towards women’s experiences in these hospitals. A number of physicians described the treatment women received at Hospital General and Hospital Pequeño as substandard, and felt constricted in their ability to improve patients’ experience in their respective hospitals. Dr. Domingo, a senior physician at Hospital General, expressed that he felt that the public hospital system placed both physicians and patients in a difficult position. He noted: I think that in the medical profession, the last thing you want to do is hurt people. You don’t study all these years to hurt or harm someone. But the volume of patients in this hospital is so high- it makes it difficult to give patients privacy or give them personalized attention. But because of the volume, you have to be very dedicated and aware of all the patients. Obviously, occasionally there can be omissions or mistakes in the treatment of patients. And this is what our fear is. We’re doing the job the best we can but certain situations might still happen that affect the patient… We’re giving this job everything we have, but still, [it feels like] we’re always on the edge of an abyss. Dr. Domingo recognizes the shortcomings of the public hospital that create challenges for physicians to provide adequate care for patients. He notes that with the large patient volume at Hospital General, physicians are unable to provide attentive care to each patient. Yet, as Dr. Domingo asserts, many of the physicians are simply trying to do their best within this environment. He notes that none of the physicians would intentionally try to harm a patient, and continually try to manage the stresses of the public hospital. In his statement that “we’re always on the edge of an abyss,” he alludes to the instability that physicians face working in this environment, constantly striving to work with many patients, limited resources, and to still avoid error or poor treatment. 146 ! ! Like senior physicians, several of the residents also expressed empathy towards patients’ experiences in Hospital General and Hospital Pequeño. Dr. Rafael, a first year resident, explained to me that he felt sometimes “the hospital here hurts patients and it’s something we [as doctors] don’t really see.” I asked him to elaborate on his comment and he explained, “For example, a patient arrives and we, the first year residents are the first to see her. We perform a vaginal exam, but sometimes the second and third year residents do not always believe us. So it turns into one, two, three exams, and by the time the senior physician comes, up to five vaginal exams in one visit.” Dr. Rafael noted that repeated vaginal exams are both painful and predispose a woman to infection. He felt that in the daily stress of working in the Toco, physicians forget about the repercussions of their actions on patients. Just as the public hospital system can be brutalizing to patients, physicians are also victimized through this system. As I discussed in Chapter 5, physicians must navigate the constraints of the public hospital system, leading to profound stress for physicians. Working over 90 hour weeks, fearing discipline by superiors, and feeling anxiety over potential lawsuits are a few of the stresses that result in a dehumanizing work environment for physicians, resulting in what Dr. Domingo describes as “always on the edge of the abyss”. Many of physicians recognize the limitations of the public hospital system and its affect on patients, yet they try to do their best within these constraints. Ultimately, the demands on physicians from the public health system negatively impacts patients’ experience, as cultural biases and social disparities are further reinforced. 147 ! ! Conclusion Intersectionality theory asserts that a multiplicity of sociocultural, political, and economic factors create a distinctive experience for particular actors, thereby shaping that individual’s views and actions. This framework is particularly useful in understanding the number of factors that result in physician microaggression towards patients. First, physicians’ conceptualizations of patients must be understood amidst a history of prejudice towards indigenous groups, particularly indigenous women. Ginsburg and Rapp’s (1995) framework of stratified reproductive is particularly salient in Mexico, given decades of efforts by the federal government to reduce reproduction among lowincome, indigenous women. Physicians viewed women at their hospitals as both irresponsible and unknowledgeable, unable to control their reproduction or care for their health. These ideas are reflected in physicians’ moral regimes, as they maintained particular ideas about how these patients should behave. Two important beliefs of physicians were that women must utilize birth control to be responsible mothers and that women who followed their instructions and accepted the pain of childbirth were cooperative. Physicians’ discussions of these ideas were often imbued with moral justifications, viewing women with large families as irresponsible and women who did not cooperate as disruptive. Physicians additionally applied different standards to women receiving C-sections in public and private institutions, understanding women in public hospitals as unable to properly care for a horizontal incision. It is critical to also consider the discrepancy in power between patient and provider in considering physicians’ interactions with patients. As discussed in Chapter 2, Jordan observes that physicians hold a form of knowledge that possesses greater 148 ! ! significance in the clinical encounter. When physicians perceive that patients do not follow their instructions, particularly in agreeing to birth control or following instructions during labor, they often reprimand patients with microaggresions. This power divide is also important in understanding why patients may not respond to physicians’ microaggressions, as in the case of Dr. Juliana and Dr. Valentina. Finally, examining the institutional context in which physicians work is essential to analyzing why microaggressions occur. I also consider that the chaotic, underfunded Mexican public hospital exacerbates physicians’ stress and reinforces their beliefs about race and class. Working exhaustive hours with limited resources, the public hospital environment serves to perpetuate existing prejudices. Just as the public hospital dehumanizes physicians, patients are reduced to objects to be moved along in an overcrowded and underfunded system. As physicians are unable to keep up with the unreasonable demands of the public hospital system, patients are blamed for being problematic. Ultimately, this chapter has argued that within this system, humane treatment and individual patient needs become secondary, as physicians struggle with the day-to-day challenges in this environment. Gender, race, social, and institutional variables all dynamically interact to produce microaggressions towards patients. Physicians’ positions within the medical system, their social standing as middle class and educated, and the daily stresses they undergo working in the public hospital system, distinctly shapes their views of patients. This chapter has argued that physicians’ perspectives and the subsequent behaviors must be understood within the specific sociocultural variables of a particular setting. ! ! 149 ! ! Chapter 7: Discussion and Conclusion: The Implications of Neoliberal Ideology on Childbirth ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 150 ! ! Introduction Medical decision-making provides a window to better understand the underlying social, economic, and cultural dynamics in a particular setting (Baer, et al. 2003; Jordan 1992; Lazarus 1994). In the introduction to this dissertation, I examined decision-making within a system of health that is premised upon the neoliberal ideology; a form of health care based on the belief that decentralizing health care in favor of a privatized system is more efficient and profitable (Harvey 2007). The use of metrics to quantify particular health outcomes is an important component of health care systems based on the neoliberal ideology, as health care organizations are able to track the actions of individuals within the system to ensure that these goals are met (Adams 2016; Erikson 2012; Sangaramoorthy and Benton 2012). While scholars have examined how the use of measurement tools, like the electronic health record, pay for performance programs, and quality indicators shape physician behavior, little is known regarding how such measures impact physicians in settings of limited resources (Hunt, et al. 2017; Magrath and Nichter 2012; Oldani 2010). Mexico provides a useful location to examine this question, as its health care system has undergone major changes in the last several decades. Along with neoliberal reforms in other areas of Latin America in the late 20th century, in Mexico, federal health expenditures were decreased and attempts were made to decentralize health care to state governments (Homedes and Ugalde 2009; Knaul, et al. 2012). In an effort to correct for the lack of medical care for low-income individuals that resulted from slashing national health expenses, the federal Mexican government passed Seguro Popular in 2003, promoting this program as a form of universal insurance for approximately half of the 151 ! ! population that remained uninsured (Dantés, et al. 2011). However, inadequate funding for Seguro Popular and poor infrastructure have resulted in continued health disparities, as public Mexican hospitals often lacked the resources and personnel necessary to keep up with this expansion (Mills 2006; Nigenda, et al. 2015). Women’s health is a particularly salient area to examine the effects of this system on health care. While the number of women who give birth in public Mexican hospitals in the last decade have surged, sufficient funding and employees have not paralleled this increase (Freyermuth 2014; Laurell 2007; Mills 2010). Additionally, Mexico is under international scrutiny for several unfavorable metrics, including maintaining the fourth highest C-section rate in the world and failing to meet the Millennial Development Goals for Maternal Mortality Rate (MMR) (Gibbons, et al 2012; Suárez 2012; WHO 2015). Yet, it remains unclear how such structures influence labor and decision-making within the public hospital system. In this dissertation, I wanted to explore how this broader social and institutional context affects physician decision-making in labor and delivery in two public Mexican hospitals. The scope of this dissertation has not been to criticize all uses of metrics, nor I do intend to invalidate the importance of measuring metrics like maternal death. Rather, I have aimed to highlight the shortcomings of utilizing metrics as a measure of health, particularly in an underfunded health system, such as Seguro Popular in Mexico. Relying solely on data or outcome measure to make medical decisions neglects to consider the specific individuals and settings in which such decisions are made. I utilized C-sections as a window through which to examine medical decision-making, as Hospital General and Hospital Pequeño’s high C-section rates suggest that the decision to elect for a C- 152 ! ! section is not strictly medical. I aimed to examine how this system impacts the individuals it was created to serve: low-income women giving birth. Ultimately, by examining decisions made within the context of Mexico’s public hospital system, I wanted to understand the specific mechanisms through which social, cultural, and economic inequality is perpetuated. Why C-sections Occur: Taking a Closer Look at Physician Beliefs In this study, I asked why physicians at Hospital Pequeño and Hospital General thought that a large number of C-sections occurred at their respective institutions. Although most physicians stated that medical indications were responsible for the majority of C-sections, throughout my observations and interviews, it became clear that a number of non-medical factors influenced their decision for a C-section. Physicians of all training levels described childbirth as a risky process that needed to be monitored through technology, yet senior physicians and residents differed in how they reconciled this belief with the limited resources of the birth ward. Senior physicians felt that given the lack of technology and spatial limitations in the birth ward, C-sections helped to ensure a safe delivery. In contrast, residents, particularly those early in their training, expressed criticism towards senior physicians’ management of labor, observing that women often weren’t given sufficient time to give birth vaginally. In exploring physicians’ decisions for a C-section, my intention was not to suggest that C-sections are never a useful or life-saving procedure. Rather, I wanted to examine the way in which institutional and social context structure physicians’ decisions, influencing their actions during childbirth. These findings demonstrate the way in which physicians’ beliefs regarding birth intersects with their institutional context, thereby 153 ! ! shaping their decisions about delivery method. Physicians’ belief that childbirth requires close management reflects the underlying biomedical view that birth is a pathological process. Yet, this idea is challenged in the context of the Mexican public hospital, which is notoriously underfunded and overcrowded. Although the aim behind Seguro Popular was to improve low-income individuals’ health through expanding insurance, flaws in the financial design of Seguro Popular have resulted an insufficient number of medical personnel for a rapidly increasing patient population and a lack of basic resources, like number of hospital beds, technology, and medications (García 2015; Notimerica 2016). Physicians must navigate this system, balancing their beliefs about how patients should be best managed within the reality of this setting. Senior physicians felt that performing a greater number of C-sections helped to mitigate the risk of an adverse outcome, as they were able to ensure that they were present during delivery and that patients moved through the overcrowded birth ward quickly. Thus, these findings illustrate that Csections at Hospital General and Hospital Pequeño do not occur only due to medical indications; rather, the institutional and social context that hospitals operate within plays a large role in shaping physicians’ decisions for a C-section. Data Performativity and Bureaucratic Demands: Creating New Realities Through Quantification While this study found that physicians’ desire to manage risk and avoid a “bad” outcome contributed to the high C-section rates at Hospital General and Hospital Pequeño, this dissertation also examined how physicians understand an adverse outcome and how this conceptualization shapes their behavior. Physicians of varying training levels perceive repercussions differently depending on their position within the system. 154 ! ! Applying Erikson’s concept of data performativity, I examined how new realities are created for physicians depending on their place within the medical system and how they explained the varying consequences or rewards for particular outcomes. Maternal mortality was a top concern for administrative physicians; they were acutely aware of the importance that the federal Mexican government and international organizations placed on lowering their MMR. For example, Dr. Isabella, an administrator at the Yucatan Ministry of Health, was concerned about loss of funding for the public hospitals in the Yucatan due to a high MMR. In contrast, Dr. Valeria and Dr. Santiago, administrators at Hospital General and Hospital Pequeño, focused on personnel changes that could take place if their hospitals’ data underperformed. Administrative physicians felt that lowering the MMR carried greater significance than other measurements, such as the C-section rate. Senior physicians and residents expressed an awareness of the varying emphasis on these metrics, acknowledging that they felt the hospital administration was apathetic towards a high C-section rate. Rather, senior physicians’ feared a poor delivery outcome because of the potential to be sued, and viewed C-sections as a safer method of delivery. Residents felt anxiety over the rigid medical hierarchy in Hospital General, asserting that following the directions of senior physicians was easier than challenging their decision. Although metrics like maternal mortality may not meaningfully reflect the complex social, cultural, and institutional dynamics of childbirth in public hospitals, these measurements profoundly impact individuals working within this system. This is not to suggest that metrics should never be utilized or that they diametrically oppose the experience of those working in health care, but rather, I argue that we must carefully 155 ! ! weigh how to interpret and apply information from strictly quantitative data. By viewing certain metrics as markers of success or failure, a new reality is created for individuals working under this framework. In the case of Hospital General and Hospital Pequeño, physicians understood that MMR remained a critically important statistic while C-section rates held less significance. While physicians’ perceptions of the consequence for an adverse event varied by training level, performing a large number of C-sections remained less concerning to physicians, as they felt that this statistic held fewer consequences. Deepening Disparity: The Effect of the Neoliberal Ideology in Health Care on Vulnerable Populations This dissertation additionally explored the impact of larger social, political, historical, and institutional variables on physicians and their subsequent interactions with patients. Through the lens of intersectionality theory, I argued that a number of factors, such as race and class based discrimination, gender, a power divide between physician and patient, and institutional structure dynamically interact to produce microaggressions towards patients. These factors distinctly shaped physicians’ moral regimes in the birth ward, as physicians maintained particular expectations for this patient population. Two important standards held by physicians for patients were that patients should control their reproduction and cooperate within the context of the birth ward. When physicians perceived patients to defy these expectations, microaggressions were apparent in physicians’ interactions with patients. Physicians’ moral regimes were also evident in examining the type of C-section incisions they performed on patients, viewing patients in the public hospital as poor candidates for a horizontal incision, while regularly opting for a horizontal incision for private hospital patients. Ultimately, the intersection of these 156 ! ! historical, political, and social factors resulted in microaggressions towards patients, exacerbating existing stereotypes. While in this way, the public hospital system seems to further marginalize vulnerable groups, it is important to note the impact of this system on physicians as well. As. Dr. Domingo’s comment illustrates, physicians are under constant stress in the public hospital system, as they experience pressure to move as many patients as possible through the birth ward, while ensuring a “good” outcome. This brutalizing system holds negative implications for physicians and their interactions with patients. Working over 90 hours weeks and barely able to tend to their own needs, the intense demands made on physicians working in the public hospital perpetuate social and cultural prejudices. The Influence of the Neoliberal Agenda on Health Care: Who Benefits? This dissertation has contributed to anthropological literature in several regards. First, this study supports previous works that contend that medical decision-making is a socially and culturally mediated process. Anthropologists have suggested that decisionmaking during childbirth is particularly dynamic, as elements like the use of technology, medication, and intervention varies immensely depending on setting (Ginsburg and Rapp 1991; Hollen 2003; Jordan 1992). This study supports this assertion, as physicians’ decisions for a C-section were closely tied to the social context of Hospital General and Hospital Pequeño. Rather than a uniform and standardized process in electing for a Csection, physicians in this study weighed multiple factors, including the occupancy of the birth ward, the potential consequence of an adverse outcome, the opinion of senior physicians, and their perception of the patient and that patient’s risk factors. Decision- 157 ! ! making for delivery method was a dynamic and fluid process for these physicians; social and cultural context was critical in shaping their behaviors. Secondly, this study illustrates that within a given social and cultural setting, it is critical to examine the specific institutional, bureaucratic, and economic structures that influence the actions of particular actors within that system. A number of anthropologists have illustrated that the unique variables within a certain setting differently influence the perspective and behaviors of those within it (Hopkins 2000; Howes-Mischel 2012; OniOrisan 2016; Wendland 2012). For example, in Matthew Dudgeon’s (2012) examination of health care providers’ conceptualizations of maternal risk in Guatemala, he found that providers’ ideas of risk were directly related to their role in the health care system. He notes that NGO workers viewed all pregnancies as risky, while physicians only saw certain pathologies as high-risk, suggesting that NGO workers’ viewpoints stem from a need to justify their projects, whereas physicians must prioritize certain cases in the hospital. Similarly, I found that physicians’ perspectives regarding labor and delivery were distinctly shaped by their position within the Mexican health care system. While state level administrators like Dr. Valeria prioritized a low MMR, senior physicians working in the maternity ward concerned with avoiding lawsuits impacted their decisions. In contrast, overwhelmed by a massive workload and situated within a rigid medical hierarchy, residents felt obeying senior physicians’ decisions for delivery method was important in electing to perform a C-section. This dissertation also adds to the anthropologic literature that turns a critical lens towards health care systems’ dependence on metrics as a measure of health. As Adams (2016) contends, metrics best reflect the priorities of the groups utilizing them, rather 158 ! ! than health realities. Sangaramoorthy and Benton (2012) point out that such priorities are particularly visible in considering what metrics do not measure. This dissertation well illustrates this point. Although a low MMR may act as a marker of success for hospital and Ministry of Health administrators, this measure obscures the reality of the birth wards at Hospital General and Hospital Pequeño, such as an overwhelming number of patients, limited resources, and physicians’ stress. Focusing heavily on maternal mortality may have unintended consequences, like promoting the use of unnecessary technologic intervention, adding to physician stress, or perpetuating racial stereotypes. If we are to truly measure health and wellbeing, these elements are critical to examine in a holistic assessment of health care. Finally, this dissertation lends insight as to how particular groups continue to remain socially, economically, and culturally marginalized. Like Smith-Oka (2015), I found that racism and class based discrimination are reproduced within Mexican public hospitals, as middle class physicians experience intense stress working within the underfunded public hospital system. She asserts that such discrimination materializes in the form of microaggressions: derogatory physical or verbal interactions with patients. This dissertation documents such mechanisms through which cultural stereotypes of indigenous groups, along with public hospital system perpetuates prejudice. When patients did not meet physicians’ expectations that they should control their reproduction and cooperate, physicians frequently admonished patients through microaggressions. This study also suggested vertical C-section incisions may be used as a physical embodiment of the cultural characterization of patients as irresponsible and high risk. 159 ! ! The intention of this dissertation has not been to suggest that metrics are useless or irrelevant to health situations or the experiences of those working within health care. Rather, I have aimed to demonstrate that relying solely upon quantitative data to understand health often neglects to consider the complex social phenomena that influence that way in which these numbers are produced. Moving forward, it is critical to consider how institutional priorities may shape health practices, ultimately further disenfranchising the individuals that it was created to serve. ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 160 ! ! ! ! ! ! ! ! ! ! ! WORKS CITED 161 ! ! WORKS CITED Abadia, Cesar Ernesto, and Diana G. Oviedo 2009 Bureaucratic itineraries in Colombia. A theoretical and methodological tool to assess managed-care health care systems. Social Science & Medicine 68(6):1153-1160. Adams, Vincanne 2016 Metrics: What counts in global health: Duke University Press. Adams, Vincanne, Sienna R Craig, and Arlene Samen 2016 Alternative accounting in maternal and infant global health. Global public health 11(3):276-294. Almeida, Sueli de, et al. 2008 Significant differences in cesarean section rates between a private and a public hospital in Brazil. Cadernos de Saúde Pública 24(12):2909-2918. Armada, Francisco, and Carles Muntaner 2004 The visible fist of the market: Health Reforms in Latin America. Unhealthy health policy. A critical anthropological examination:29-42. Baer, Hans A., Merrill Singer, and Ida Susser 2003 Medical anthropology and the world system: Greenwood Publishing Group. Ballinas, Victor 2009 La salud pública se brinda en condiciones deficientes: CNDH. http://www.jornada.unam.mx/2009/05/12/politica/005n1pol, accessed July 15, 2017. Barber, Sarah L. 2010 Mexico’s conditional cash transfer programme increases cesarean section rates among the rural poor. European Journal of Public Health 20(4):383-388. Barker, Kristin K 1998 A ship upon a stormy sea: The medicalization of pregnancy. Social Science & Medicine 47(8):1067-1076. Barros, Aluísio JD, et al. 2011 Patterns of deliveries in a Brazilian birth cohort: almost universal cesarean sections for the better-off. Revista de saude publica 45(4):635-643. Barros, Fernando Celso de, et al. 1991 Epidemic of caesarean sections in Brazil. The Lancet 338(8760):167-169. 162 ! ! Bassett, Ken L, Nitya Iyer, and Arminee Kazanjian 2000 Defensive medicine during hospital obstetrical care: a by-product of the technological age. Social Science & Medicine 51(4):523-537. Batalla, Guillermo Bonfil, and Philip A Dennis 1996 México profundo: Reclaiming a civilization: University of Texas Press. Beagan, Brenda L 2000 Neutralizing differences: producing neutral doctors for (almost) neutral patients. Social Science & Medicine 51(8):1253-1265. Becker, Sven, et al. 2007 Meconium-stained amniotic fluid—Perinatal outcome and obstetrical management in a low-risk suburban population. European Journal of Obstetrics & Gynecology and Reproductive Biology 132(1):46-50. Behague, Dominique P 2002 Beyond the simple economics of cesarean section birthing: women's resistance to social inequality. Culture, Medicine and Psychiatry 26(4):473-507. Béhague, Dominique P, Cesar G Victora, and Fernando C Barros 2002 Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. Bmj 324(7343):942. Belizán, José M, Fernando Althabe, and Maria Luisa Cafferata 2007 Health consequences of the increasing caesarean section rates. Epidemiology 18(4):485-486. Berry, Nicole S 2013 Unsafe motherhood: Mayan maternal mortality and subjectivity in postwar Guatemala. Volume 21: Berghahn Books. Betrán, Ana Pilar, et al. 2016 The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PloS one 11(2):e0148343. Biruk, Crystal 2012 Seeing like a research project: Producing “high-quality data” in AIDS research in Malawi. Medical anthropology 31(4):347-366. Blanc, Ann K., et al. 2016 Measuring progress in maternal and newborn health care in Mexico: validating indicators of health system contact and quality of care. BMC Pregnancy and Childbirth 16(1):255. 163 ! ! Briggs, Charles L 2003 Stories in the time of cholera: Racial profiling during a medical nightmare: Univ of California Press. Burt, Richard D, Thomas L Vaughan, and Janet R Daling 1988 Evaluating the risks of cesarean section: low Apgar score in repeat Csection and vaginal deliveries. American journal of public health 78(10):13121314. Carrillo, Ana María 1999 Nacimiento y muerte de una profesión: las parteras tituladas en México. Dynamis: Acta Hispanica ad Medicinae Scientiarumque. Historiam Illustrandam 19:167-190. Casas Patiño, Donovan; Rodríguez Torres, Alejandra; Casas Patiño, Isaac; and Cuauhtémoc Galeana Castillo 2013 Médicos residentes en México: tradición o humillación. Medwave 13(7). Castro, Arachu, and Merrill Singer 2004 Unhealthy health policy: A critical anthropological examination. Walnut Creek, CA: AltaMira. Castro, Roberto, and Joaquina Erviti 2003 Violations of reproductive rights during hospital births in Mexico. Health and human rights:90-110. — 2015 25 años de investigación sobre violencia obstétrica en México. Revista CONAMED 19(1). Caughey, Aaron B, et al. 2014 Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology 210(3):179-193. CDI, Comisión Nacional Para El Desarrollo de los Pueblos Indíginas 2010 La mortalidad materna indígena y su prevención CDI, Comisión Nacional Para El Desarrollo de los Pueblos Indíginas. Chary, Anita, and Peter Rohloff 2015 Privatization and the new medical pluralism: Shifting healthcare landscapes in Maya Guatemala: Lanham, MD: Lexington Books. CIFRHS, Comisión Interinstitucional Para La Formación de Recursos Humans Para La Salud Comité de Posgrado y Educación Continua 164 ! ! 2012 Examen Nacional Para Aspirantes A Residencias Medicas: Características y Evolución a su formato electrónico. Secretaría de Salud y Secretaría de Educación Pública Clarke, Adele E., and Janet K. Shim 2009 Medicalization and biomedicalization Revisited: technoscience and transformations of health, illness and biomedicine. Salute e Società. CONEVAL, Consejo Nacional de Evaluación de la Politica de Desarrollo Social 2012a Evaluacion Estrategica sobre Mortalidad Materna en Mexico 2010: caracterısticas sociodemograficas queobstaculizan a las mujeres embarazadas su acceso efectivo a instituciones de salud. CONEVAL. — 2012b La pobreza en la población indígena de 2012. Cosminsky, Sheila 2001 Maya midwives of southern Mexico and Guatemala. Mesoamerican healers:179-210. Craven, Christa 2007 A" consumer's right" to choose a Midwife: Shifting meanings for reproductive rights under neoliberalism. American Anthropologist:701-712. D'Gregorio, Rogelio Pérez 2010 Obstetric violence: a new legal term introduced in Venezuela. International Journal of Gynecology & Obstetrics 111(3):201-202. Dantés, Octavio Gómez, et al. 2011 Sistema de salud de México. salud pública de méxico 53:s220-s232. Davis, Kathy 2003 Surgical passing: or why Michael Jackson's nose makesus' uneasy. Feminist Theory 4(1):73-92. Davis-Floyd, Robbie E. 1987 Obstetric training as a rite of passage. Medical Anthropology Quarterly:288-318. Davis-Floyd, Robbie, and Cecilia van Hollen 1994 Birth as an American rite of passage. Culture, medicine and psychiatry 18(4):501-512. Davis Floyd, Robbie, and Elizabeth Davis 1996 Intuition as authoritative knowledge in midwifery and homebirth. Medical anthropology quarterly 10(2):237-269. 165 ! ! De Vries, Raymond, et al. 2002 Birth by design: Pregnancy, maternity care and midwifery in North America and Europe: Routledge. Deeb-Sossa, Natalia 2007 Helping the “Neediest of the Needy” An Intersectional Analysis of MoralIdentity Construction at a Community Health Clinic. Gender & Society 21(5):749-772. Delvecchio Good, Mary-Jo 2007 The medical imaginary and the biotechnical embrace: subjective experiences of clinical scientists and patients. In Subjectivity: Ethnographic Investigations. J. Biehl, B. Good, and A. Kleinman, eds. Pp. 362-380. CA: University of California Press. Diniz, Simone G, and Alessandra S Chacham 2004 “The cut above” and “the cut below”: the abuse of caesareans and episiotomy in São Paulo, Brazil. Reproductive health matters 12(23):100-110. Dixon, Lydia Zacher 2014 Obstetrics in a time of violence: Mexican midwives critique routine hospital practices. Medical Anthropology Quarterly. Dudgeon, Matthew R 2012 Conceiving Risk in K’iche’Maya Reproduction. Nashville, TN: Vanderbilt University Press. Dumit, Joseph 2012 Drugs for life: how pharmaceutical companies define our health: Duke University Press. Dumond, Don E. 1997 The Machete and the Cross: Campesion Rebellion in Yucatán. Lincoln: University of Nebraska Press. Edmonds, Alexander 2007 ‘The poor have the right to be beautiful’: cosmetic surgery in neoliberal Brazil. Journal of the Royal Anthropological Institute 13(2):363-381. Elliott, Carl 2010 White coat, black hat: adventures on the dark side of medicine: Beacon Press. Erikson, Susan L 2012 Global health business: the production and performativity of statistics in Sierra Leone and Germany. Medical anthropology 31(4):367-384. 166 ! ! Exteriores, Secretaría de Relaciones 2007 General Law on Women's Access to a Life Free of Violence. National Institute for Women. Farmer, Paul 2003 Pathologies of power: health, human rights, and the new war on the poor. Volume 4. Berkeley: University of California Press. — 2006 AIDS and Accusation: Haiti and the Geography of Blame: Univ of California Press. Farmer, Paul, et al. 2004 An anthropology of structural violence 1. Current anthropology 45(3):305325. Fiedler, Deborah Cordero 1996 Authoritative knowledge and birth territories in contemporary Japan. Medical Anthropology Quarterly 10(2):195-212. Frenk, Julio, et al. 2003 Evidence-based health policy: three generations of reform in Mexico. The Lancet 362(9396):1667-1671. Freyermuth, Graciela; Luna, Marisol, and Jose Muños 2014 Materna Mortalidad. Observatorio de Mortalidad Materna en Mexico. Gabbert, Wolfgang 2001 Social categories, ethnicity and the state in Yucatan, Mexico. Journal of Latin American Studies 33(03):459-484. Gaines, Atwood D., and Robbie Davis-Floyd 2004 Biomedicine. In Encyclopedia of medical anthropology. Pp. 95-109: Springer. Gakidou, E., R. Lozano, and E. González-Pier 2006 Assessing the effect of the 2001–06 Mexican health reform: an interim report card. Lancet 368. Gamlin, Jennie B 2013 Shame as a barrier to health seeking among indigenous Huichol migrant labourers: An interpretive approach of the “violence continuum” and “authoritative knowledge”. Social science & medicine 97:75-81. Gamlin, Jennie B., and Sarah J. Hawkes 167 ! ! 2014 Pregnancy and birth in an indigenous Huichol community: from structural violence to structural policy responses. Culture, health & sexuality 17(1):78-91. García, Jesus 2015 Mal Servicio en Hospitales, Por Medicos Sobresaturados. http://www.milenio.com/region/Mal_servicio_hospitalesmedicos_sobresaturados_Ciudad_Madero_0_507549302.html. Gibbons, Luz, et al. 2012 The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. World health report 30:1-31. Ginsburg, Faye D., and Rayna Rapp 1995 Conceiving the new world order: The global politics of reproduction: Univ of California Press. Ginsburg, Faye, and Rayna Rapp 1991 The politics of reproduction. Annual review of Anthropology:311-343. Good, Byron J 1993 Medicine, rationality and experience: an anthropological perspective: Cambridge University Press. Gutiérrez JP, Rivera-Dommarco J, Shamah-Levy T, Villalpando-Hernández S, Franco A, et al. 2012 Encuesta Nacional de Salud y Nutrición 2012. Resultados Nacionales. Instituto Nacional de Salud Publica. 2012. Hafferty, Frederic W, and Ronald Franks 1994 The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine 69(11):861-71. Hahn, Robert A 1987 Divisions of labor: Obstetrician, woman, and society in Williams obstetrics, 1903–1985. Medical Anthropology Quarterly 1(3):256-282. Harvey, David 2007 A brief history of neoliberalism: Oxford University Press, USA. Hendrix, Susan L, et al. 2000 The legendary superior strength of the Pfannenstiel incision: a myth? American journal of obstetrics and gynecology 182(6):1446-1451. Hetzel, H, et al. 168 ! ! 1979 Caesarean section: low transverse (pfannenstiel) or midline incision?(author's transl). Zeitschrift fur Geburtshilfe und Perinatologie 183(2):128-135. Hogan, M. C., K. J. Foreman, and M. Naghave 2010 Maternal mortality for 181 countries, 1980–2008: systematic analysis of progress towards Millenium Development Goal 5. Lancet 375. Hojat, Mohammadreza, et al. 2009 The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Academic Medicine 84(9):1182-1191. Hollen, Cecilia Van 2003 Invoking vali: painful technologies of modern birth in south India. Medical Anthropology Quarterly 17(1):49-77. Homedes, Núria, and Antonio Ugalde 2005 Why neoliberal health reforms have failed in Latin America. Health policy 71(1):83-96. 2009 Twenty-five years of convoluted health reforms in Mexico. PLoS Medicine 6(8):e1000124. Hopkins, Kristine 2000 Are Brazilian women really choosing to deliver by cesarean? Social science & medicine 51(5):725-740. Howes-Mischel, Rebecca 2012 Local Contours of Reproductive Risk and Responsibility in Rural Oaxaca. Nashville: Vanderbuilt University Press. Hunt, Linda M, et al. 2017 Electronic Health Records and the Disappearing Patient. Medical Anthropology Quarterly. Hunt, Linda M., Meta Kreiner, and Howard Brody 2012 The changing face of chronic illness management in primary care: a qualitative study of underlying influences and unintended outcomes. The Annals of Family Medicine 10(5):452-460. Hyatt, Susan Brin 1999 Poverty and the medicalisation of motherhood. Sex, Gender, and Health. Teresa M. Pollard and Susan Brin Hyatt, eds:94-117. INEGI, Instituto Nacional de Estadistica y Geografia 2015 !!Principales resultados de la Encuesta Intercensal 2015. INEGI. 169 ! ! INEGI, Instituto Naciónal de Estadística y Geografía 2010 Censo de Población y Vivienda 2010. Instituto Naciónal de Estadística y Geografía (INEGI). Iriart, Celia, Emerson Elıas Merhy, and Howard Waitzkin 2001 Managed care in Latin America: the new common sense in health policy reform. Social Science & Medicine 52(8):1243-1253. Jordan, Brigitte 1992 Birth in four cultures: A crosscultural investigation of childbirth in Yucatan, Holland, Sweden, and the United States: Waveland Press. — 1997 Authoritative knowledge and its construction. Childbirth and authoritative knowledge: Cross-cultural perspectives:55-79. Jordan, Brigitte, and Robbie Davis-Floyd 1993 Birth in four cultures: a crosscultural investigation of childbirth in Yucatan, Holland, Sweden, and the United States. Prospect Heights, Ill: Waveland Press. Joseph, Gilbert M 1985 From Caste War to Class War: The Historiography of Modern Yucatán (c. 1750-1940). The Hispanic American Historical Review 65(1):111-134. King, Malcolm, Alexandra Smith, and Michael Gracey 2009 Indigenous health part 2: the underlying causes of the health gap. The Lancet 374(9683):76-85. Kleinman, Arthur, Leon Eisenberg, and Byron Good 1978 Culture, illness, and care: clinical lessons from anthropologic and crosscultural research. Annals of internal medicine 88(2):251-258. Klimpel, Jill, and Risa Whitson 2016 Birthing modernity: spatial discourses of cesarean birth in São Paulo, Brazil. Gender, Place & Culture 23(8):1207-1220. Knaul, Felicia Marie, and Julio Frenk 2005 Health insurance in Mexico: achieving universal coverage through structural reform. Health affairs 24(6):1467-1476. Knaul, Felicia Marie, et al. 2012 The quest for universal health coverage: achieving social protection for all in Mexico. The Lancet 380(9849):1259-1279. Knight, Alan 170 ! ! 1990 Racism, revolution, and indigenismo: Mexico, 1910-1940. In The idea of race in Latin America, 1870-1940. Austin: University of Texas Press. Krasner, Michael S, et al. 2009 Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Jama 302(12):1284-1293. Lambert, Helen 2006 Accounting for EBM: notions of evidence in medicine. Social science & medicine 62(11):2633-2645. Langer, A., J. Frenk, and R. Horton 2012 Women and Health Initiative: integrating needs and response. Lancet 380. Laurell, Asa Cristina 2007 Health system reform in Mexico: a critical review. International Journal of Health Services 37(3):515-535. Laveaga, Gabriela Soto 2007 “Let’s become fewer”: Soap operas, contraception, and nationalizing the Mexican family in an overpopulated world. Sexuality Research & Social Policy 4(3):19-33. Lazarus, Ellen S. 1994 What do women want?: Issues of choice, control, and class in pregnancy and childbirth. Medical Anthropology Quarterly 8(1):25-46. Leatherman, Thomas L., and Alan Goodman 2005 Coca-colonization of diets in the Yucatan. Social Science & Medicine 61(4):833-846. Leavitt, Judith Walzer 1983 " Science" Enters the Birthing Room: Obstetrics in America since the Eighteenth Century. The Journal of American History 70(2):281-304. Localio, A Russell, et al. 1993 Relationship between malpractice claims and cesarean delivery. Jama 269(3):366-373. Loewe, Ronald 2010 Maya Or Mestizo? Nationalism, Modernity, and its Discontents. Toronto: University of Toronto Press. Magrath, Priscilla, and Mark Nichter 171 ! ! 2012 Paying for performance and the social relations of health care provision: an anthropological perspective. Social science & medicine 75(10):1778-1785. Majety, Chandramathi, and Sravani Bejugam 2016 Challenges and barriers faced by women in accessing justice against obstetric violence. Mattiace, Shannan L 2009 Ethnic mobilization among the Maya of Yucatán. Latin American and Caribbean Ethnic Studies 4(2):137-169. McCall, Leslie 2005 The complexity of intersectionality. Signs: Journal of women in culture and society 30(3):1771-1800. McCallum, Cecilia 2005 Explaining caesarean section in Salvador da Bahia, Brazil. Sociology of health & illness 27(2):215-242. Mills, Lisa 2006 Maternal health policy and the politics of scale in Mexico. Social Politics 13(4):487-521. — 2010 Citizenship, reproductive rights, and maternal health in Mexico. Canadian Journal of Development Studies/Revue canadienne d'études du développement 31(3-4):417-438. Molina, Rose Leonard, and Daniel Palazuelos 2014 Navigating and circumventing a fragmented health system: the patient's pathway in the Sierra Madre Region of Chiapas, Mexico. Medical anthropology quarterly 28(1):23-43. Morales, Yolanda 2014 #YoSoy17, No Somos Dioses, Somos Medicos. El Economista, June 20, 2014. Morgan, Lynn M, and Elizabeth FS Roberts 2012 Reproductive governance in Latin America. Anthropology & medicine 19(2):241-254. Mulligan, Jessica M 2014 Unmanageable Care: An Ethnography of Health Care Privatization in Puerto Rico: NYU Press. Murray, Susan F 172 ! ! 2000 Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study. Bmj 321(7275):1501-1505. Mylonas, Ioannis, and Klaus Friese 2015 Indications for and risks of elective cesarean section. Deutsches Ärzteblatt International 112(29-30):489. Nations, United 2015 2013: MDG Acceleration and Beyond 2015, Vol. 2017. Nigenda, Gustavo, et al. 2015 Evaluating the Implementation of Mexico's Health Reform: The Case of Seguro Popular. Health Systems & Reform 1(3):217-228. Notimerica 2016 Desabastecidos y sobresaturados, la dramática situación de los hospitales mexicanos. http://www.notimerica.com/sociedad/noticiaNdesabastecidosN sobresaturadosNdramaticaNsituacionNhospitalesNmexicanosN 20160708155238.html. O'Connor, Bonnie B 1993 The home birth movement in the United States. The Journal of medicine and philosophy 18(2):147-174. Oakley, Ann 1984 The captured womb: A history of the medical care of pregnant women. OECD 2005 OECD Reviews of Health Systems: Mexico 2005: OECD Publishing. Oldani, Michael J 2004 Thick prescriptions: toward an interpretation of pharmaceutical sales practices. Medical Anthropology Quarterly 18(3):325-356. — 2010 Assessing the ‘relative value’of diabetic patients treated through an incentivized, corporate compliance model. Anthropology & medicine 17(2):215228. Oni-Orisan, Adeola 2016 The Obligation to Count: The Politics of Monitoring Maternal Mortality in Nigeria. In Metrics: What Counts in Global Health. V. Adams, ed. Durham, NC: Duke University Press. Passalacqua, Stacey A, and Chris Segrin 173 ! ! 2012 The effect of resident physician stress, burnout, and empathy on patientcentered communication during the long-call shift. Health communication 27(5):449-456. Pfeiffer, James, and Rachel Chapman 2010 Anthropological perspectives on structural adjustment and public health. Annual Review of Anthropology 39:149-165. Pfeiffer, James, and Mark Nichter 2008 What can critical medical anthropology contribute to global health? Medical anthropology quarterly 22(4):410-415. PROSPERA, Programa de Inclusión Social 2016 Reglas de Operación de PROSPERA Programa de Inclusión Social. Gobierno de Mexico. Puig, Andrea, José A Pagán, and Rebeca Wong 2009 Assessing Quality across Health Care Subsystems in Mexico. The Journal of ambulatory care management 32(2):123. Quadros, LG 2000 Caesarean section controversy. Brazilian obstetricians are pressured to perform caesarean sections. BMJ (Clinical research ed.) 320(7241):1073; author reply 1074-1073; author reply 1074. Reed, Nelson 1964 The Caste War of Yucatan. Stanford, CA: Stanford University Press. Roberts, Elizabeth FS 2012 Scars of nation: surgical penetration and the Ecuadorian state. The Journal of Latin American and Caribbean Anthropology 17(2):215-237. Robles, Laura Catalina Díaz, and Luciano Oropeza Sandoval 2007 Las parteras de Guadalajara (México) en el siglo XIX: el despojo de su arte. Dynamis: Acta Hispanica ad Medicinae Scientiarumque Historiam Illustrandam 27:237-261. Rockhill, Beverly 2001 The privatization of risk. American journal of public health 91(3):365. Rodríguez-Angulo, Elsa, et al. 2009 Subregistro de muertes maternas en comunidades mayas del oriente de Yucatán, México. Revista Biomédica 20(2):90-98. Rugeley, Terry 174 ! ! 2010 Yucatan's Maya peasantry and the origins of the caste war: University of Texas Press. Ryan, Gery W, and H Russell Bernard 2003 Techniques to identify themes. Field methods 15(1):85-109. Rylko Bauer, Barbara, and Paul Farmer 2002 Managed Care or Managed Inequality? A Call for Critiques of Market Based Medicine. Medical anthropology quarterly 16(4):476-502. Sadler, Michelle, et al. 2016 Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reproductive Health Matters. Salud, Secretaría de 2008 PROGRAMA DE ACCIÓN ESPECÍFICO 2007-2012: Planificación Familiar y Anticoncepción. Sangaramoorthy, Thurka, and Adia Benton 2012 Enumeration, identity, and health. Medical anthropology 31(4):287-291. SEDESOL, Consejo Nacional de Evaluación de la Politica de Desarrollo Social CONEVAL and Secretaría de Desarrollo Social 2015 Informe Anual Sobre La Situación de Pobreza Y Rezago Social 2015. Silver, Robert M, et al. 2006 Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology 107(6):1226-1232. Singer, Merrill 1986 Developing a critical perspective in medical anthropology. Medical Anthropology Quarterly 17(5):128-129. Smith-Oka, V. 2012a Bodies of risk: constructing motherhood in a Mexican public hospital. Soc Sci Med 75(12):2275-82. Smith-Oka, Vania 2012b They don’t know anything”: How medical authority constructs perceptions of reproductive risk among low-income mothers in Mexico. Risk, reproduction, and narratives of experience:103-122. — 2013a Managing Labor and Delivery among Impoverished Populations in Mexico: Cervical Examinations as Bureaucratic Practice. American Anthropologist 115(4):595-607. 175 ! ! — 2013b Shaping the motherhood of Indigenous Mexico: Vanderbilt University Press Nashville, TN. — 2015 Microaggressions and the reproduction of social inequalities in medical encounters in Mexico. Social Science & Medicine 143:9-16. Stocker, Karen, Howard Waitzkin, and Celia Iriart 1999 The exportation of managed care to Latin America. New England Journal of Medicine 340(14):1131-1136. Storeng, Katerini T, and Dominique P Béhague 2017 “Guilty until proven innocent”: the contested use of maternal mortality indicators in global health. Critical Public Health 27(2):163-176. Suárez, Leticia et al 2012 Encuestra Nacional de Salud y Nutricion: Evidencia para la política pública en salud. Instituto Nacional de Salud Pública. Suñer-Soler, Rosa, et al. 2014 The consequences of burnout syndrome among healthcare professionals in Spain and Spanish speaking Latin American countries. Burnout Research 1(2):8289. Tamez González, Silvia, and Catalina Eibenschutz 2008 El seguro popular de salud en México: pieza clave de la inequidad en salud. Revista de Salud Pública 10(1). Toral-Villanueva, Rodrigo, Guadalupe Aguilar-Madrid, and Cuauhtémoc Arturo JuárezPérez 2009 Burnout and patient care in junior doctors in Mexico City. Occupational Medicine 59(1):8-13. Trueba, G 1994 Midwifery in Mexico. Modern midwife 4(4):28-29. Tussing, A Dale, and Martha A Wojtowycz 1997 Malpractice, defensive medicine, and obstetric behavior. Medical care 35(2):172-191. Unger, Jean-Pierre, et al. 2008 Chile's neoliberal health reform: an assessment and a critique. PLoS Med 5(4):e79. Van Bogaert, L-J, and A Misra 176 ! ! 2008 Neonatal outcome after caesarean birth for fetal distress and/or meconium staining in a South African rural setting. Journal of Obstetrics and Gynaecology 28(1):56-59. Vega, Rosalynn Adeline 2016 Commodifying Indigeneity: How the Humanization of Birth Reinforces Racialized Inequality in Mexico. Medical Anthropology Quarterly. Velázquez Leyer, Ricardo, and Juan Pablo Ferrero 2016 Social Policy Expansion, Democracy and Social Mobilization in Latin America: Healthcare Reform in Brazil and Mexico. Journal of Iberian and Latin American Research 22(2):117-134. Victora, Cesar G., et al. 2015 Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival. The Lancet 387(10032):2049-2059. Villaseñor, Thamara 2014 Confirman negligencia de IMSS Jalisco, dictan prisión a 16 médicos. Informador, June 4, 2014. Wade, Peter 2008 Race in Latin America. Deborah A. Poole, A Companion to Latin American Anthropology, Malden/Oxford, Blackwell. Wells, Allen 1992 All in the Family: Railroads and Henequen Monoculture in Porfirian Yucatan. The Hispanic American Historical Review 72(2):159-209. Wendland, Claire 2007 The Vanishing Mother: Cesarean Section and Evidence Obstetrics . Medical Anthropology Quarterly 21(2):218-233. Based — 2012 Moral maps and medical imaginaries: clinical tourism at Malawi's college of medicine. American Anthropologist 114(1):108-122. — 2016 Estimating death: A close reading of maternal mortality metrics in Malawi. In Metrics: What counts in global health. Durham, NC: Duke University Press. Global Public Health. V. Adams, ed. Durham, NC: Duke University Press. Williams, Sarah A 2016 Ideal citizens: the birthing of state truths and fictions in Quintana Roo. Anthropology & medicine 23(3):332-343. World Health Organization (WHO) 177 ! ! 2004 Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO, ICM and FIGO. — 2014 The prevention and elimination of disrespect and abuse during facilitybased childbirth: WHO statement. — 2015a A Decade of Tracking Progress for Maternal, Newborn and Child Survival Countdown Headlines for 2015 Vol. 2017. — 2015b WHO Statement on Caesarian Section Rates. Wylie, Blair J, et al. 2010 Comparison of transverse and vertical skin incision for emergency cesarean delivery. Obstetrics and gynecology 115(6):1134. ! 178 !