The Dangers of Childbirth in Southern Mexico

SAN CRISTOBAL DE LAS CASAS, Mexico (April 20) -- Among dozens of other brightly dressed women, Eugenia Urbina has been waiting on the stairs of the main hospital in this central Chiapas town for nearly two hours. Nine months pregnant with her third child, the 24-year-old seeks prenatal care. The long wait makes her worry that when the time comes to give birth, the hospital will not have room for her.

"It happens a lot," Urbina said, and if it does, she'll have to pay more than she can afford to drive around in a taxi for up to an hour to find a clinic that can take her.

It's not just a question of inconvenience. The brutal drug gang murders sweeping across Mexico have captured the headlines. But a more insidious killer stalks the south of the country, where women in Mexico's poorest states -- many of them indigenous -- are dying in childbirth at nearly twice the rate of the national average.

A study published this month in the British medical journal The Lancet found that maternal mortality is falling in most countries, including Mexico, where overall maternal death rates dropped from 152 per 100,000 births in 1980 to 52 in 2008. (For comparison, the 2008 rate was four in Italy, 17 in the United States and 1,575 in Afghanistan.)

But the differential within the country is stark, and the problem is particularly acute in the poorest southern states of Chiapas, Oaxaca and Guerrero. More than 1 million people in Chiapas, most of whom are indigenous, do not have access to health care, according to SIPAZ, a poverty research group.

For pregnant women, health advocates say, poverty can equal death. "Because those deaths are in most of the cases avoidable, maternal mortality is a good indicator of social inequalities," said Beatriz Duarte-Gomez, a researcher with the Mexican National Institute of Public Health. While Mexico's maternal mortality rate isn't the worst in the region, World Bank statistics indicate that it's higher than that of other countries with the same economic indicators.

Most childbirth deaths result from a lack of prompt medical care or, in some cases, botched treatment by undertrained staff. For the largely rural population that suffers the brunt of this crisis, even the difficulty of getting to a medical treatment center can lead to fatal delays. In 2008, a woman giving birth bled to death right in front of a clinic in the rural town of Betania, about an hour outside of San Cristobal.

The economic downturn has exacerbated poverty, since many low-income Mexicans depend on foreign remittances. "What happens in the global economic crisis directly affects these small communities in Oaxaca, Chiapas and Guerrero," said Ximena Avellaneda Diaz, the research coordinator for a woman's reproductive rights advocacy group in Oaxaca.

Maternal mortality is a barometer of the sharp divisions in Mexican society over class and race. Indigenous women are three times more likely to die in childbirth than nonindigenous women, in part because one out of three indigenous births in rural areas is done without assistance from a health care worker.

In the poorest areas, there is simply a lack of doctors. Travel can be long and difficult to organize, with the trip to a hospital or clinic lasting 12 hours on bad roads for some women due to give birth. And even when a doctor is available, communication is a problem since many indigenous women speak little or no Spanish and translation services are often not available.

Language is not the only gap to be bridged. Doctors sometimes give women recommendations that they cannot follow, according to Dr. Adriana Luna Castellanos of Marie Stopes International, a British reproductive health organization with four clinics in Chiapas. "The doctor tells a mother to relax, when she has to walk two miles for water or grind the corn for the tortillas," she said. "Or to sleep in a soft bed when she has a wooden bed. The advice the doctors give them is not fitted for these people."

Sometimes a mother dies not from lack of care, but from poor medical treatment at a hospital. Improper medication and surgical mishaps -- such as poorly executed or unnecessary cesarean sections -- are both leading causes of maternal mortality, according to data from Mexico's Ministry of Health.

Complications from botched abortion attempts are another big problem, according to a report by the MacArthur Foundation, which has put more than $5 million toward the problem of maternal mortality. Abortion is illegal in every state of Mexico except the capital.

The findings published in The Lancet suggest that with political will and funding, maternal mortality can be reduced. "More of this needs to be aimed at specifically vulnerable areas of these highly affected states, especially areas where indigenous people live -- and women die," said Deborah Billings, a professor of public health at the University of South Carolina, who co-authored the MacArthur study. "These are the specific pockets where not enough political will has been focused."

Until that political will is created and translated into culturally competent services, more clinics and increased coverage by midwives, childbearing women of southern Mexico will continue dying at unacceptably high rates.

Reporting for this story was funded in part by the Pulitzer Center on Crisis Reporting. Translation assistance by Cynthia Mazariegos.