Abstract

Obstetric healthcare for Indigenous women remains a severe problem in low-income countries with great cultural diversity and a colonial past. The work of health professionals to prevent complications leading to maternal deaths is paramount, yet in these contexts, they face significant challenges in implementing culturally competent services. This paper aims to present findings from an ethnographic study that attempted to document the experience of health professionals providing obstetric services in order to show the complex sociocultural contexts in which they perform their work.

Key words:
Indigenous health services; Complication in obstetric labor; Health professions; Indigenous population; Women’s health

Introduction

In Mexico, in 2022, almost 20% of its total population identified themselves as Indigenous (23 million people who speak 68 Indigenous languages)¹1 Instituto Nacional de Estadística Geografía e Informática (INEGI). Comunicado de prensa núm. 430/22 [Internet]. 8 de agosto de 2022. [acceso 2024 mar 26]. Disponible en: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.inegi.org.mx/contenidos/saladeprensa/aproposito/2022/EAP_PueblosInd22.pdf
https://www.inegi.org.mx/contenidos/sala... . Designing public health policies to address their heterogeneity is a shared challenge in the Americas region²2 Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS). Prestación de servicios de salud en zonas con pueblos indígenas. Quito: OPS/OMS; 2009.

3 Gutiérrez JP, Heredia-Pi I, Hernández-Serrato MI, Pelcastre-Villafuerte BE, Torres-Pereda P, Reyes-Morales H. Desigualdades en el acceso a servicios, base de las políticas para la reducción de la brecha en salud. Salud Publica Mex 2019; 61(6):726-733.^-44 Organización Panamericana de la Salud (OPS). Encuentro Internacional Salud y Pueblos Indígenas: Logros y Desafíos en la Región de las Américas. Washington, D.C: OPS; 2003.. One of the challenges is to have enough health professionals trained in interculturality²2 Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS). Prestación de servicios de salud en zonas con pueblos indígenas. Quito: OPS/OMS; 2009.^,55 Meneses-Navarro S, Pelcastre-Villafuerte BE, Bautista-Ruiz Óscar A, Toledo-Cruz RJ, de la Rosa-Cruz SA, Alcalde-Rabanal J, Mejía-Marenco JA. Innovación pedagógica para mejorar la calidad del trato en la atención de la salud de mujeres indígenas. Salud Publica Mex. 2021; 63(1):51-59., who work in rural and highly marginalized areas, to address health needs in PHC units since one of the problems related to the sufficiency of health professionals is the high turnover in these facilities⁶6 León-Bórquez R, Lara-Vélez VM, Abreu-Hernández LF. Educación médica en México. FEM 2018; 21(3):119-128.. This situation chiefly occurs because some are attended by medical students who perform community service for a year⁷7 Roco-Zúñiga AL, Domínguez-Naranjos J, Méndez-Martínez S, Ramírez-Dueñas LK, Fernández-Vázquez MU, Hernández-Domínguez J. Perspectiva de los médicos pasantes de Medicina en la selección de la modalidad del servicio social. Rev Edu Desarrollo 2021; 57:41-47.. Initiatives have been developed from the health governing level to promote the permanence of health professionals in rural areas, offering better salaries as an incentive. However, there is still a shortage of health professionals in the regions with the highest percentage of Indigenous population, which generates inequalities in access to health care³3 Gutiérrez JP, Heredia-Pi I, Hernández-Serrato MI, Pelcastre-Villafuerte BE, Torres-Pereda P, Reyes-Morales H. Desigualdades en el acceso a servicios, base de las políticas para la reducción de la brecha en salud. Salud Publica Mex 2019; 61(6):726-733.^,88 Nigenda G, Alcalde-Rabanal J, González-Robledo LM, Serván-Mori E, García-Saiso S, Lozano R. Eficiencia de los recursos humanos en salud: una aproximación a su análisis en México. Salud Publica Mex 2016; 58(5):533-542..

On the other hand, the provision of health services occurs through different health subsystems, made up of institutions that offer services for two population profiles: those that provide social security for salaried workers and those that serve the population without social security (such as Indigenous people)⁹9 Gómez-Dantés O, Sesma S, Bercerril VM, Kanaul FM, Arreola H, Frenk J. Sistema de salud de México. Salud Publica Mex 2011; 53(Supl. 2):S220-S232.. In 2023, a new healthcare model was launched, aimed at universalizing health and based on PHC. The model considers the intercultural approach a vital element to train health human resources in grasping other models of understanding health-disease, considering that this way promotes the quality of care provided to the indigenous population¹⁰10 Diario Oficial de la Federación. DOF: 17/01/2024. Programa Institucional de Servicios de Salud del Instituto Mexicano del Seguro Social para el Bienestar (IMSS-BIENESTAR) 2023-2024.^,1111 Diario Oficial de la Federación. DOF: 27/12/2021. PROGRAMA Especial de los Pueblos Indígenas y Afromexicano 2021-2024.. This initiative follows the recommendations of international organizations that have promoted this topic as an essential element of training to improve care quality; additionally, the model considers expanding the human resource base and health infrastructure to serve approximately 53 million people currently without social security¹²12 Instituto Mexicano del Seguro Social (IMSS). IMSS-Bienestar atenderá a 53.2 millones de personas sin seguridad social; será el modelo más grande del planeta [Internet]. 2023. [acceso 2024 mar 26]. Disponible en: https://www.imss.gob.mx/prensa/archivo /202308/433#:~:text=El%20director%20general% 20del%20Instituto,atenci%C3%B3n%20m%C3%A1 s%20grande%20del%20planeta
https://www.imss.gob.mx/prensa/archivo /... .

In Mexico, the universe of people who enter to study health professions do so in 165 public and private medical schools and faculties⁶6 León-Bórquez R, Lara-Vélez VM, Abreu-Hernández LF. Educación médica en México. FEM 2018; 21(3):119-128.. Also, some intercultural universities offer health areas for undergraduate graduation. Although we could not find any reliable source recording the number of health professionals working exclusively in Indigenous areas, the complexity involved in organizing their care can be appreciated with data from 2011 that refers to 20,920 outpatient units in these regions, without this meaning that it is the total infrastructure or human resources available for their care¹³13 Comisión Nacional de Derechos Humanos. El derecho a la salud de los pueblos indígenas. Servicios y atención en las clínicas de las comunidades [Internet]. 2015. [acceso 2024 mar 26]. Disponible en: https://www.cndh.org.mx/sites/all/doc/cartillas/2015-2016/04-Salud-Pueblos-Indigenas.pdf
https://www.cndh.org.mx/sites/all/doc/ca... .

An example of inequality in access to health is obstetric emergency care, which is defined as an event that endangers the life of women and their babies during the pregnancy-childbirth-postpartum period and requires immediate attention by qualified medical personnel¹⁴14 Secretaría de Salud. Triage Obstétrico, Código Mater y Equipo de Respuesta Inmediata Obstétrica. Lineamiento Técnico. Centro Nacional de Equidad de Género y Salud Reproductiva, Secretaría de Salud. Ciudad de México; 2016.. In contexts with insufficiently trained personnel and inadequate hospital infrastructure, it can lead to the worst outcome of obstetric emergency, which is maternal death (from now on, MD). MD is more frequent in countries with high levels of poverty and social and health inequalities, such as in Latin American and African countries¹⁴14 Secretaría de Salud. Triage Obstétrico, Código Mater y Equipo de Respuesta Inmediata Obstétrica. Lineamiento Técnico. Centro Nacional de Equidad de Género y Salud Reproductiva, Secretaría de Salud. Ciudad de México; 2016.

15 Jaffré Y. Towards an anthropology of public health priorities: maternal mortality in four obstetric emergency services in West Africa. Social Anthropology 2012; 20(1):3-18.

16 Pourette D, Pierlovisi C, Randriantsara R, Rakotomanana E, Mattern C. Avoiding a "big" baby: Local perceptions and social responses toward childbirth-related complications in Menabe, Madagascar. Soc Sci Med 2018; 218:52-61.

17 Schwartz DA, editor. Introduction to Indigenous Women and Their Pregnancies: Misunderstood, Stigmatized, and at Risk, Maternal Death and Pregnancy-Related Morbidity Among Indigenous Women of Mexico and Central America. New York: Springer; 2018.^-1818 Salim B, Delamou A, Grovogui FM, Kok BC, Benova L, El Ayadi AM, Gerrets R, Grietens KP, Delvaux T. Interventions to increase facility births and provision of postpartum care in sub-Saharan Africa: a scoping review. Reproductive Health 2021(4):16., which hinder access to timely and quality care during the prenatal stage, childbirth, and postpartum. Approximately 75% of MDs are associated with hemorrhages, preeclampsia, complications during childbirth and abortions, and most of these complications are supposedly treatable.¹⁹19 Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, Gülmezoglu AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2(6):e323-e333.

How to reduce MD is an issue that has generated great academic and political debates worldwide. The United Nations and the World Health Organization have promoted several initiatives to prevent it²⁰20 World Health Organization (WHO). Partnership for maternal, newborn & child health report: commitments to the every woman every child global strategy for women's children's and adolescents' health (2016-2030). Geneva: WHO; 2020.. From the social disciplines, especially Applied Medical Anthropology and Medical Sociology, a significant amount of theoretical and empirical knowledge has contributed to analyzing this critical issue. An ethnographic work on MD among Indigenous women has documented poverty as the main determinant²¹21 Scheper-Hugues N. Death Without Weeping: The Violence of Everyday Life in Brazil. Berkley: University of California Press; 1992.; the work of midwifery vs. institutionalized care²²22 Davis-Floyd R. La partera profesional: articulating identity and cultural space for a new kind of midwife in Mexico. Med Anthropol 2001; 20(2-3):185-243.; obstetric violence as a breach of trust in the medical care offered by public health services²³23 Castro R. Hacia una sociología de la anticoncepción forzada en México. En: Karina Bárcenas Barajas, coordenador. Género y sexualidad en disputa, Desigualdades en el derecho a decidir sobre el propio cuerpo desde el campo médico. CDMX: UNAM; 2021. p. 37-64.; and the influence of gender roles that demand women’s attention to their family and delay the search for medical care²⁴24 Gamlin J, Gibbon S, Sesia PM, Berrio L. Critical medical anthropology, perspectives in and from Latin America. London: UCL Press; 2020.. However, to a lesser extent, some academic knowledge has been produced on obstetric emergencies and MD from the perspective of health professionals working in Indigenous contexts.

As can be seen, few details are known about the professionals who go to work in remote areas, and regarding MDs, how they address obstetric emergencies daily. Finally, what are the challenges to offering culturally competent obstetric services? This article aims to show these complex realities.

Methods

The data presented in this article are nested in a more extensive study developed in Argentina, Mexico and Peru, which had several objectives. Only a part of the qualitative component conducted in one of the Mexican states where information was obtained from health professionals is presented here²⁵25 Nigenda G, Maceira D, Juárez-Ramírez C, Lazo O. Mejorando la calidad de la atención a la salud materna de mujeres indígenas en Argentina, México y Perú: síntesis ejecutiva. Cuernavaca: Universidad Autónoma del Estado de Morelos; 2020.. The method used was ethnographic²⁶26 Nader L. Ethnography as theory. J Ethnographic Theory 2011; 1(1):211-219. through four visits during 2017 and 2018 in Mixteca Baja, Oaxaca State (Figure 1). A network of health services²⁷27 Pan American Health Organization. Integrated health service delivery networks: concepts, policy options and a road map for implementation in the Americas. Washington, DC: PAHO; 2010. was identified in rural areas where Indigenous women go to receive sexual and reproductive healthcare. It consisted of five primary care medical units (each in a rural town) and two referral hospitals for childbirth and obstetric emergencies in the urban area closest to these towns. Secondary sources were consulted as part of the method used, and data was retrieved from primary sources (individual interviews).

Data collection: first, non-participant observation periods were conducted to document the itineraries followed by women for childbirth care: from rural health centers to the hospital; subsequently, observation was conducted within the medical facilities to record how the care circuit occurred and the participation of each health professional in the process. As a result, to construct the sample, at least one health professional was chosen to be interviewed, and the criterion was that they had some role in the pregnancy and childbirth care circuit (see Table 1). Additionally, two representatives of civil society organizations (CSOs) that supported the stay of women and their families in the city while they were attending the birth were interviewed. In total, 20 health professionals and two CSO members were interviewed.

Data analysis: all interviews were audio-recorded and subsequently transcribed verbatim. For this article, manual coding was performed, analyzing line by line, as suggested by the Constructivist Grounded Theory²⁸28 Charmaz K. Constructing Grounded Theory. A Practical Guide through Qualitative Analysis. London: SAGE Publications; 2006. (Figure 2). Information concentrates were prepared by topic and type of health personnel interviewed.

Ethical aspects: informed verbal consent was obtained.²⁹29 World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013; 310(20):2191-2194. The research protocol was approved by the Research Ethics Committees of the National Institute of Public Health of Mexico on September 6, 2016, under project n° 1.416. Because this is a sensitive topic, the names of the towns where the fieldwork was conducted and the sensitive data of the health personnel who agreed to be interviewed have been eliminated to ensure their anonymity.

Results

The healthcare context

The institutional network for providing medical services comprised five primary care units serving 20 small communities, and two secondary care hospitals serving people without social security. The trip to the most remote village we reached took three hours on a paved road and sidewalks. This is very important for the care of obstetric emergencies since transfers to the hospital depend on public transport services.

Regarding the pregnancy-birth-postpartum process, the medical management organization plans that health centers will perform activities to promote family planning and follow-up of the prenatal care stage through monthly appointments; for delivery care, women are referred to the hospital and return to their communities once the baby is born. A typical health personnel team in rural medical units consists of only one doctor and one nurse. However, due to the size of the population they serve or because they are located in a strategic area (geographically), some other units provide other services besides medical care, such as nutritional, psychological, or dental guidance; in these cases, the health team is more extensive. The nursing staff provides the link between the outgoing medical staff (who only work for one year) and the incoming one. Generally, these medical units have a nurse with a ‘baseline’ contract type, and doctors and other health professionals in social service do not have a permanent contract (Table 1). In rural areas, medical personnel made the medical unit their home; they usually stayed there to sleep during the week and returned to the city with their families on the weekend; only the health promoters and volunteers lived with their families in the town where they worked. One of the main observations that drew attention was the lack of health personnel serving these populations and the distance of health centers from the town center, with the social and gender violence risks that this entailed.

Training in obstetric emergencies

Once a month, they received training on medical emergencies and new regulations, generally to identify symptoms and warning signs during the prenatal and postpartum stages; and on interculturality, respect for local culture, patients’ rights and the importance of finding translators to communicate since language was one of the principal communication barriers. Despite the training received, those interviewed reported being afraid of facing a case of maternal death since they knew stories about the reaction of the residents to such situations. One interviewed nurse recalled the following experience:

Previously, births were attended in these rural medical units. However, doing so represented a risk in the event of complications since these units do not have the necessary equipment, instruments, and human resources. Most of the medical staff interviewed did not know the area where they came to work.

Community observers and obstetric surveillance

In these communities, there is free collective community work called tequio; it is a social organization form for the community’s good. The different tasks are distributed annually in a community assembly. Women occupy tasks related to their gender. According to the ‘uses and customs’ of these locations, being responsible for health is typical. Thus, they are sent to medical units to help health personnel organize activities and are called Health Promoters, Auxiliaries, or Volunteers. They received training on First Aid and identifying preeclampsia symptoms and signs. They collaborated by completing referral forms to the hospital for obstetric emergencies and informed women in the community on these topics. Some had first aid kits in their homes to perform minor healing or give medicine that did not require a prescription. This social organization form is linked to the regulations of the public health subsystem in the region analyzed, which demands the population’s participation to extend the work of health personnel and achieve greater empathy. As a result, the community provided human resources for the institutional health model. A Human Development Program linked to health was in place during the research years. When some of these promoters had small children, they received a little money from this Program, which was an additional motivation to participate as a promoter in the medical unit. Moreover, some promoters received a small monthly salary from the Program for their support as spokespersons in the community and assistance to health personnel since one of the difficulties faced by health personnel was attracting women during the prenatal care period to begin monitoring the pregnancy and prevent complications. Above all, they said, young women did not usually go to the medical unit during the first months of pregnancy, because of a desire to hide their pregnancy (especially if they were teenagers without a partner); shame of being observed by medical personnel; and to ‘not generate gossip’ about them. Because of this, the promoters were the principal resource to attract women to appointments. The following dialogue occurred with a promoter during fieldwork:

I am in charge of checking pregnant women, identifying them as soon as possible before three months to refer them here to the clinic so they can start taking their iron and folic acid and have good control over their pregnancy.

How do you identify pregnant women?

Some of these promoters achieve community recognition for their work. However, they also receive aggression from women who want to keep their pregnancies a secret: “Who told you I was pregnant? I have nothing,” women often tell them; they hide the pregnancy until it starts to become noticeable. One of the doctors interviewed commented on this:

Although they have hospitals… they come late to start their prenatal care check-ups… the volunteers and health promoters are constantly looking for new cases of pregnant women. They go house to house identifying new pregnant women and those who have already been identified who are attending prenatal care check-ups (Gynecologist-obstetrician, Hospital 2).

Most frequent obstetric emergencies

Preeclampsia was one of the most frequently treated emergencies. Some doctors interviewed commented that emergencies were complicated by the distance between the village and the hospital where the birth was being attended to. Also, women waited until the last minute to go to the hospital, only being admitted when labor was already well underway. Because of the frequency of these complications, the women and their nursing staff would make a ‘safety plan’ to make the necessary community arrangements in case of an emergency or when the time came to give birth. The plan included arranging aspects of their home: with whom they would leave their children, who would feed them, and who would take care of their animals:

Upon returning from the hospital, once the delivery has been attended to, women must go to the medical unit for their postpartum check-up, where they are explained the risk of puerperal sepsis. This infection is common and very risky for the mother:

Obstetric emergencies in adolescent women

The medical staff agreed that obstetric emergencies frequently occur among young women in this region. Despite the additional work of the promoters, volunteers, and brigade members, they cannot ensure that women follow adequate prenatal care, with follow-up clinical studies and ultrasounds to have evidence of the baby’s proper growth. One of the doctors interviewed described it as a “cultural problem,” she said. In this region, it is “customary” for families to marry off women as soon as they begin to menstruate, considering that they can already become mothers. Another doctor commented:

Regulations indicate that pregnant women must receive nine prenatal care appointments, and prenatal care should ideally begin with pregnancy planning. However, women generally go three or four months into pregnancy:

This situation is made up of several circumstances, one of which, mentioned by both medical and nursing staff, is the meager success they have regarding recommending birth control to women and the importance of spacing pregnancies. Another aspect is that it is challenging to speak openly about the issues of family planning methods in these locations because they are communities with autonomous authorities of Indigenous peoples who disagree that women should be spoken to about these issues. One of the doctors recalled that it is expected to receive letters from these local authorities prohibiting them from disseminating information on sexual and reproductive health. Since violence against health personnel has occurred, they avoid confronting the population so as not to put themselves at risk, although this lack of freedom to inform about contraceptive options has consequences for women. The interviewed epidemiologist who worked at one of the hospitals in the obstetric care network recalled that, in 2018, 233 of 1,295 deliveries attended to at the hospital were in adolescent women (18%). He considered that early pregnancy is associated with maternal deaths and occurs mainly in the most remote areas of the city. The same epidemiologist recalled that ‘marital arrangements’ continue to operate in that region, generally between older men and younger women. Once married, the women stay in the village pregnant, and the men return to work in the United States or other cities. These, she said, are situations that occur daily. Pregnancy complications and emergencies develop during this social dynamic of the communities. It also happens that women leave their communities to work in the cities, they emigrate temporarily looking for job opportunities, sometimes they get pregnant and return to their community of origin to attend the birth; in the cities, if they have discomfort, they usually go to clinics adjacent to pharmacies because of the low cost of the medical appointment, but they do not receive prenatal care.

One of the social workers at one of the referral hospitals agreed with the health personnel in stating that they are not getting good results with their work to prevent unwanted pregnancies at early ages. She considered that these teenage women face such situations when they become pregnant when they do not have a partner and must continue living with their parents. However, due to prohibitions by traditional authorities on providing information on family planning in communities, ‘it is difficult to pass on this information to young people’. The psychology service provided by a social service student in one of the largest medical units in the area conducted activities on mental health with young people, including pregnant adolescent women. It commented that it was faced with a population with whom they needed to do much work to get them to attend their prevention talks since the psychology service was somewhat foreign to their care practices. One of the psychology service faculties was to refer cases to specialized psychological support areas in hospitals. However, this service was in low demand and was practically not used.

Communication

Language was identified by those interviewed as a permanent difficulty faced by health personnel, limiting the communication they could have with women and their families. A specialist doctor at the hospital described it as follows:

Social workers at the hospital get people to translate. One social worker interviewed recalled a situation:

Discussion

Many reflections can be made on the findings presented here and countless academic works published on the topics addressed. The information provided is an outline of the territory’s richness and devaluation and the social vulnerability of the population. Health professionals face institutional deficiencies in performing their work and in their beliefs regarding the actions of the population with which they work.

International organizations have proposed an intercultural approach to healthcare to train health personnel and achieve better quality of care³⁰30 Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS). Política sobre etnicidad y salud, 29ª Conferencia Sanitaria Panamericana. Washington, DC: OPS/OMS; 2017.. However, there is evidence in the region showing that this approach is limited in light of the diversity of Indigenous peoples’ fundamental needs, which must be improved so that the trained professionals’ work bears fruit²2 Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS). Prestación de servicios de salud en zonas con pueblos indígenas. Quito: OPS/OMS; 2009.. One of the criticisms of this approach lies in the lack of the voice of Indigenous populations in planning health activities⁴4 Organización Panamericana de la Salud (OPS). Encuentro Internacional Salud y Pueblos Indígenas: Logros y Desafíos en la Región de las Américas. Washington, D.C: OPS; 2003., and in the case of maternal health care, from a feminist perspective, the lack of gender equity³¹31 Varea S, Zaragocin S, compiladores. Feminismo y buen vivir, utopías decoloniales. Cuenca: Pydlos Ediciones; 2017.. For reasons of space, we will refer to three aspects as a summary and a note for further study of this critical problem.

The lag in institutional healthcare devices in rural communities and its intersection with the Indigenous culture

A fact to be recognized above and beyond the circumstances faced by health personnel in conducting their work is that these rural regions remain marginalized from advances in medical technology compared to urban areas, which is an obstacle to making timely diagnoses of obstetric emergencies. On the other hand, as shown by the work of observation and review of historical data from the region, these societies preserve ancestral cultural practices of care for the pregnancy-birth-postpartum process, which coexist with biomedical care. For example, seeking support from midwives for various tasks (such as ‘settling the child’) or performing rituals such as using ‘temazcales’ in the postpartum period (steam baths of pre-Hispanic origin to help deliver the placenta) are standard practices. These practices underpin part of the social organization around family life and contribute to the social fabric. They are linked to others that need to be put into perspective, for example, the social acceptance of pregnancy at an early age, unions with older men, and forced marriage, as also occurs in other Mexican states³²32 Luna-Pérez J, Nazar-Beutelspacher A, Mariaca-Méndez R, Ramírez-López DK. Matrimonio forzado y embarazo adolescente en indígenas en Amatenango del Valle, Chiapas. Una mirada desde las relaciones de género y el cambio reproductivo. Papeles Población 2021; 106:35-73..

On the other hand, they face the challenge of the prohibition of local indigenous authorities to provide information on contraception. Part of the negative assessment of the role of health personnel in childbirth by the authorities of these Indigenous communities derives from the experiences of women who have suffered from a lack of infrastructure and supplies during obstetric care, which has been documented in another article³³33 Juárez-Ramírez C, Villalobos A, Sauceda-Valenzuela AL, Nigenda G. Barriers for indigenous women to access obstetric services within the framework of integrated health services networks. Gac Sanit 2020; 34(6):546-552.. These aspects have their specific weight for social reproduction forms. There will be voices in favor of respect for their autonomy and others for the informed decisions of women about their bodies and the number of children they wish to bear. The truth is that all these circumstances combined result in women attending medical appointments late. The complexity of sociocultural frameworks produces what Kleinman called social suffering³⁴34 Kleinman A. Concepts and a model for the comparison of medical systems as cultural systems. Soc Sci Med 1978; 12(2B):85-93. and a local framework built around moral norms - that Csordas has studied as a cultural system³⁵35 Csordas TJ. Morality as a cultural system? Current Anthropol 2013; 54(5):523-546. - that dictate acceptable daily practices, combined with the environment of poverty. In the case of women in this region, this scenario marks their course from birth, and local morality allows them even to be exchanged for goods. In this sense, it is urgent to resume the discussion on the implication of cultural relativism for human rights from an ethical perspective³⁶36 Dundes A. The unanswered challenge of relativism and the consequences for human rights. Hum Rts Q 1985; 7(4):514-540.^,3737 Kleinman A. Moral experience and ethical reflection: can ethnography reconcile them? A quandary for "the new bioethics. Daedalus 1999; 128(4):69-97..

The healthcare model

Medical evidence points to the importance of adequate prenatal monitoring to oversee any risk situation. However, the context studied is riddled with multiple barriers that explain the lack of success in the work of health personnel to attract pregnant women and attend to the prenatal period. Biomedical systems, seen as cultural systems³⁴34 Kleinman A. Concepts and a model for the comparison of medical systems as cultural systems. Soc Sci Med 1978; 12(2B):85-93., provide health-disease care models. In the case studied, a care model that manages to expand the work of health personnel through the voluntary work of people from the community who act as promoters is still being used. This type of care organization has been widely used since the 1970s in low-income countries, where Primary Care was prioritized, and the population was encouraged to be involved in preventive activities³⁸38 World Health Organization (WHO), Pan American Health Organization (PAHO). Universal health in the 21st century, 40 years of Alma-Ata, report of the High-Level Commission. Washington DC: WHO; 2019.. However, we must question their validity and ask ourselves how much the models used align with the generations of young women, who, despite restrictions in these Indigenous communities, may have access to information through the Internet and mobile phones and other experiences outside the community.

Revisiting the medical power

Another body of theoretical knowledge has been produced around the culture that has historically been created about the medical profession and health professionals, differentiating those who study medicine (doctors) and the subordination of other disciplines that assist them, such as nursing. In his classic work³⁹39 Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Dodd, Mead and Co; 1970. on the medical profession, Freidson analyzes medical professionals in their various roles, including as disseminators of the State’s ideology on health and creators of a status of power⁴⁰40 Foucault M. Naissance de la Clinique. Paris: Quadrige/Puf; 1988. conferred by their knowledge of the human body, its manipulation, and the symbolic burden granted to them by the medical institution. These conceptual frameworks argue that medical professionals imbue and embody this culture⁴¹41 Csordas TJ. Embodiment as a paradigm for anthropology. Ethos 2009; 18(1):5-47., thus creating an institutional environment of hegemony-subordination in the doctor-patient encounter.⁴²42 Menéndez EL. Hacia una práctica médica alternativa. Hegemonía y autoatención (gestión) en salud. Ciudad de México: Casa Chata-Ciesas; 1983. These arguments are often used to explain what is considered a lack of empathy between those who provide medical care and those who demand care. According to these arguments, it seems that health personnel fail to adapt to lay contexts, which influences the acceptability of medical care. However, the findings presented here show other facets, several layers of circumstances that overlap and embody the problem. The staff working in the region is far from the social representation around health professionals. They conduct their activities in a subordinate manner to local authorities. In an environment of social violence, they are careful in their practice to avoid the population referring to them as personnel who abuse their position or being stigmatized for having attended a case of complicated birth that resulted in maternal death. They do not practice in large hospitals but in facilities that lack supplies, instruments, and adequate infrastructure to address obstetric emergencies and are subject to State regulations on their work. In other words, we should refer to the precariousness of the medical profession and study what this represents for the population and professionals and from a perspective of ethics and labor rights⁴³43 Souza BL, Souza TGP Limeira CCH, Borges HC, Pereira NC. Precarização do vínculo de trabalho do médico na Paraíba: reflexos éticos. Rev Bioet 2021; 29(2):384-393..

As a conclusion and a note for further research on this topic, we attempted to show an often-sidelined viewpoint by presenting the voices of health workers here. This article has shown that attention to obstetric emergencies and its worst consequence, maternal death, is only the tip of the iceberg of a sociocultural framework that builds the vulnerability of women from childhood. With the data presented here, we can affirm that the participation of multiple social stakeholders and political actions of the State are required to positively influence the improvement of the health personnel’s response.

Acknowledgments

To the International Development Research Center (IDRC), Canada, which funded this research.

References

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History