Midwives and Mothers: The Medicalization of Childbirth on a Guatemalan Plantation. Sheila Cosminsky. Austin: University of Texas Press, 2016, 318 pp.
In Midwives and Mothers, Sheila Cosminsky provides a detailed narrative of changes in midwifery identity and practice over the course of her 40 years of fieldwork on a Guatemalan plantation. At its core, the book focuses on a mother (María) and daughter (Siriaca) pair, both midwives with whom Cosminsky has worked extensively. Rather than inferring cultural change from interviews at a single point in time, the time-depth and intergenerational nature of her research provides Cosminsky a truly unique perspective from which to address the processes of medicalization and culture change and how these are embedded within larger socioeconomic and political changes at the local, national, and global levels.
While Cosminsky details the ways in which medicalization is fostered through pressures from national and international government and health systems, she also demonstrates that medicalization is not simply a top-down process driven by increasing regulation. Rather, it is also driven by women’s desires and expectations as well as midwives’ own pragmatic evaluations of the value of adopting new models or maintaining continuity in their beliefs, practices, and identities within the changing sociocultural and economic context of the plantation. Cosminsky thus demonstrates the dynamic and sometimes contested processes of medicalization and illustrates how continuity is not the failure of practitioners to adapt, but rather the result of midwives’ active negotiations, albeit sometimes on unequal terms, with health systems, local political and economic structures, and the women they serve.
The book is well organized, as the first chapter provides an overview of birth as “socially produced and culturally constructed” process and “the role midwives play” (p. 1) as well as the theoretical concept of medicalization. Cosminsky employs Lowis and McCaffey’s (2000) model of medicalization that highlights changes for five levels: technological, conceptual, interactional, control, and gender/status. This framework structures the organization of the manuscript and Cosminsky’s discussion of the different elements of midwifery practice and identity. Combining ethnographic interviews and survey data, Chapters 2 and 3 contextualize midwifery practice, health-related beliefs, practices, and conditions within the changing socioeconomic structure of the plantation as the owners adapt to national and international economic pressures that impact the living conditions of the plantation residents as well as the processes of medicalization. Cosminsky is one of the few anthropologists who have conducted research of any kind on a Guatemalan plantation, despite the plantations’ centrality in economic and political structure of the country, and these chapters provides a rare glimpse into the life of individuals living on plantations.
The next four chapters detail the various aspects of midwifery practice, moving sequentially from prenatal care to labor and delivery, postnatal care, and, finally the various roles and responsibilities of midwives beyond childbirth. Cosminsky illustrates midwives’ roles in each of these central domains while also emphasizing the diverse roles and relationships that midwives have with the women they serve. She shows how their practices are influenced by their own knowledge and experience, their formal training, the structure of the plantation, and women’s own requests and desires. She effectively highlights the similarities and differences between María and Siriaca by interweaving their stories throughout the chapters rather than separating them into independent sections.
Chapter 9 focuses on midwifery training programs offered by the Guatemalan Ministry of Health as well as NGOs. While there are several studies that examine the impact of training programs on midwives, the detailed case studies presented show the diversity of agendas, pedagogies, and interactions with midwives between programs and across time that help illuminate the history and future of midwifery practice.
In the conclusion, Cosminsky returns to Lowis and McCaffery’s model of medicalization and details the processes occurring in each of the five levels over time. While medicalization involves the restriction of midwives’ practices, increasing hierarchical relationships and turning birth into a medical condition stripped of its social significance and context, María and Siriaca demonstrate that midwives are “pragmatic and eclectic” (p. 246) in the incorporation of biomedical beliefs and practices into existing ethnomedical models. They actively seek to improve their practices while responding to institutional pressures as well as women’s own desires. Though the World Health Organization currently promotes the elimination of lay midwives, Cosminsky sees some hope for their continued place in Guatemalan healthcare, given their central role in providing comprehensive care in places biomedical systems fail to reach. She concludes with several recommendations for improving the relationships between midwives, biomedical providers, and the state. In addition to improving the pedagogical and practical aspects of training programs, Cosminky emphasizes the importance of moving beyond the “blame the midwife” narrative embedded in many health programs and improving the level of respect afforded to midwives by biomedical services and providers.
Cosminsky’s use of ethnographic and survey data, along with participant observation through every aspect of midwifery practice she discusses, provides a thorough understanding of the topics. The greatest limitation, which Cosminsky herself notes, is that the study does not have the same level of survey data for the 2000s as it does for the 1970s when she conducted her original study. While this limits direct comparison in terms of community-level health beliefs and living conditions, the ethnographic data from midwives, women, and individuals on the plantation in the contemporary period provide a compelling case for her arguments regarding larger changes in health conditions, beliefs, and practices on the plantation.
Midwives and Mothers is a valuable contribution to midwifery and Guatemalan studies, yet it engages with theoretical perspectives, methodological issues, and central concepts of culture change that extend beyond these two areas of study. The most direct comparison to this manuscript is Barbara Rogoff’s (2011) Developing Destinies, which also provides a case study of a Mayan midwife over time in relation to larger sociocultural and politico-economic changes. In contrast to Cosminsky’s first-hand ethnographic data, however, Rogoff relies heavily on Benjamin and Louis Paul’s field notes for the historical component and does not have the expertise in midwifery studies to adequately contextualize contemporary issues in Guatemalan midwifery practice and identity. Nicole Berry’s (2010) Unsafe Motherhood also deals with contemporary midwifery practice around Lake Atitlán in Guatemala, although the focus of the manuscript is not specifically about midwives but rather about how global health policies play out at the community level and often conflict with local concepts of family, reproduction, and kinship as well as structural barriers and ethnic discrimination that exist within the healthcare system. Cosminsky’s work, her first monograph on midwifery, thus makes a unique contribution to an existing literature that she herself helped to shape.
The book is well written and accessible to readers at all levels of experience. Midwives and Mothers could be adopted for undergraduate and graduate courses in a wide range of disciplines and courses, particularly medical anthropology, the anthropology of reproduction, and Latin American studies.
Berry, N. 2012. Unsafe Motherhood: Mayan Maternal Mortality and Subjectivity in Post-war Guatemala. New York: Berghahn Books.
Lowis, G., and P. McCaffey. 2000. Sociological Factors Affecting the Medicalization of Midwifery. In Midwifery and the Medicalization of Childbirth: Comparative Perspectives, edited by E. Van Teijlingen, G. Lowis, P. McCaffery, and M. Porter, 5–41. Huntington, NY: Nova Science Publishing.
Rogoff, B. 2011. Developing Destinies: A Mayan Midwife and Town. New York: Oxford University Press.