Claiming respectable American motherhood: homebirth mothers, medical officials, and the state

Based on ethnographic research regarding public policy and grassroots organizing for midwifery in Virginia, this article explores how medical discourses around appropriate health care practices intersect with state discourses about what practices are considered "respectable" versus "pathological" for its citizens. In recent legislative debates about the legalization of direct-entry midwifery, medical officials have extended their criticism of midwifery and homebirth to mothers who resist state-sanctioned childbirth practices. This article examines how medical officials challenge the respectable mothering practices of homebirthers by linking them with women they deem pathological--child abusers, negligent mothers, and drug users--and placing them outside the cadre of "normal" American mothers who acknowledge the "logical" and "natural" superiority of biomedical childbirth practices. I also address homebirth mothers' responses, which assert that their political advocacy for midwives is a respectable mothering practice because they are responsible citizens who desire what they deem the best care for their children.     

Pluralism and pragmatism: knowledge and practice of birth in Morocco

This article examines knowledge and practice surrounding birth in Morocco, using women's narratives of their recent birth experiences, observations of medical encounters, and statements about prescribed behaviors during pregnancy and birth, as well as the vocabulary used to refer to physiological processes, disease conditions, and social relationships. The analysis shows that the three major themes that define the traditional Moroccan ethnophysiology of birth--conceptions of hot and cold, the symbolism of blood, and the metaphors of openness and obstruction--are not inconsistent with the precepts of biomedicine and public health and do not in themselves constitute obstacles either to safe home births or the use of formal health services. Women integrate biomedical and local knowledge and practices and simultaneously seek care from "traditional" and "modern" practitioners, creatively combining elements in accordance with their situations and the means at their disposal. Birth narratives show the eclecticism and flexibility that characterize women's attitudes and behaviors regarding pregnancy and birth. Women's decisions are shaped by two overriding considerations: incertitude about what can happen during the last phase of a pregnancy and ambivalence toward the available alternatives for care, both of which reflect a realistic assessment of their situations. By showing how women make decisions in response to these considerations, this article seeks to clarify some of the links between beliefs and practices and to contribute to ongoing discussions regarding the relevance of local knowledge for patterns of health care.     

"Kissing a Baby Is Not at All Good for Him": Infant Mortality, Medicine, and Colonial Modernity in the U.S.-Occupied Philippines

Feminist scholars have begun to consider the ways indigenous practices of child rearing were and are challenged in (post)colonial discourse and practice, and how these practices have become a terrain on which definitions of nation, state, and economy are contested. In this article, I adopt a historical anthropological approach to consider how Filipino child-rearing strategies were described and stigmatized in educational, public health, and public welfare discourses in the U.S.-occupied Philippines in the early 20th century. I demonstrate how public health practices and discourses that were generated as part of a "benevolent" campaign against high rates of infant mortality were strategically used as a weapon against Filipino arguments for independence. I also consider how discourses constructing Filipino caregivers as overly indulgent were linked to metropolitan concerns about production of the "new industrial man" and were used to develop a racialized critique of the cultural practices of Filipinos.     

Medicalizing homelessness: the production of self-blame and self-governing within homeless shelters

This article draws upon three years of ethnographic research within an emergency homeless shelter in Massachusetts to explore the subject-making effects of routine shelter helping practices. A medicalized discourse of deviancy is uncovered that provides the dominant conceptual framework within which both concerned homeless people and shelter staff remain enmeshed. As a result, helping practices focus on detecting, diagnosing, and treating understood deviancy within the bodies or selves of homeless people. The dominant discursive practices produce homeless subjects who learn to look within their selves for the "cause" of their homelessness. Treatment focuses on reforming and governing the self. Alternative discourses suggesting the need for practices challenging broader political economic processes are thus marginalized as peripheral and unreasonable.     

"Even if you know everything you can forget": health worker perceptions of mobile phone text-messaging to improve malaria case-management in Kenya

This paper presents the results of a qualitative study to investigate the perceptions and experiences of health workers involved in a a cluster-randomized controlled trial of a novel intervention to improve health worker malaria case-management in 107 government health facilities in Kenya. The intervention involved sending text-messages about paediatric outpatient malaria case-management accompanied by "motivating" quotes to health workers' mobile phones. Ten malaria messages were developed reflecting recommendations from the Kenyan national guidelines. Two messages were delivered per day for 5 working days and the process was repeated for 26 weeks (May to October 2009). The accompanying quotes were unique to each message. The intervention was delivered to 119 health workers and there were significant improvements in correct artemether-lumefantrine (AL) management both immediately after the intervention (November 2009) and 6 months later (May 2010). In-depth interviews with 24 health workers were undertaken to investigate the possible drivers of this change. The results suggest high acceptance of all components of the intervention, with the active delivery of information in an on the job setting, the ready availability of new and stored text messages and the perception of being kept 'up to date' as important factors influencing practice. Applying the construct of stages of change we infer that in this intervention the SMS messages were operating primarily at the action and maintenance stages of behaviour change achieving their effect by creating an enabling environment and providing a prompt to action for the implementation of case management practices that had already been accepted as the clinical norm by the health workers. Future trials testing the effectiveness of SMS reminders in creating an enabling environment for the establishment of new norms in clinical practice as well as in providing a prompt to action for the implementation of the new case-management guidelines are justified.     

A defense of conscientious objection: Why health is integral to the permissibility of medical refusals

Schuklenk, Smalling, and Savulescu put forth four conditions that delineate when conscientious objection is impermissible. Roughly, they argue for the following claim: if some practice is legal, standard, expected of a profession, and in the patient's interest, then medical professionals cannot refuse to perform the practice. In this essay, I argue that these conditions are not jointly sufficient to deny medical professionals the ability to refuse to perform procedures that detract from a patient's health. They are insufficient to bar medical refusals to perform certain practices because, even when these conditions are met, non-health conducive practices would not be open to refusal by the physician. I provide an example of a non-health conducive practice female genital mutilation, which meets all of the proposed conditions but, intuitively, should be open to medical refusals. As a result, I conclude that the proposed conditions are insufficient to determine when conscientious objection is impermissible. I then offer an amendment to their position by suggesting that a practice, in addition to the other four conditions, must also be health conducive in order to remove the medical professional's ability to refuse to perform the practice.     

Dissin' "the Standard": Ebonics as Guerrilla Warfare at Capital High

This article analyzes the discourse styles, including the linguistic practices, of a group of African American high school students and offers a twofold conclusion: (1) Ebonics or Black English is the norm against which all other speech practices are evaluated by the students at the research site and (2) "the standard"—that is, the standard English dialect—is constructed as a vernacular. As a vernacular, this discourse is not privileged; indeed, it is "dissed" (disrespected) and is only "leased" by the students on a daily basis from nine to three. This linguistic practice is centrally implicated in the postulated guerrilla warfare at the school. With data from a predominantly African American high school in Washington, D.C., the effects of this practice on African American academic achievement are documented. Several policy implications are also noted.     

Articulating silences: experiential and biomedical constructions of hypertension symptomatology

In this article, we explore the flexible configuration of a local knowledge system about hypertension symptoms, foregrounding it against prevailing biomedical assertions regarding the asymptomatic or "silent" nature of hypertension. The complex and coherent knowledge system held by older African Americans living in a southern, rural community stands in contrast to the current scientific discourse and local biomedical perspectives on hypertension symptomatology. The older African American participants in this study apply local knowledge of hypertension symptomatology to make health decisions nearly every day. Despite this, most biomedical practitioners maintain a distance from these lay sources of knowledge, often remaining stalwart in their refusal to recognize the existence or influence of symptoms. We conclude that authoritative knowledge ultimately lies in the minds and bodies of the elders, who have encountered symptoms as guideposts that direct action, rather than with a biomedical "reality" that is yet unresolved.     

Female Genital Surgeries: The Known, the Unknown, and the Unknowable

This article reviews the literature on female genital surgeries and examines the extent to which available research supports commonly accepted "facts" about the prevalence and harmful effects of these practices, in particular their possible health complications, and their effect on sexuality. While information regarding the prevalence of female genital surgeries is becoming increasingly available, the powerful discourse that depicts these practices as inevitably causing death and serious ill health, and as unequivocally destroying sexual pleasure, is not sufficiently supported by the evidence. The article discusses some of the implications of research on female genital surgeries for the societies that are involved—not merely those where the practices are found, but also those whose gaze has been so intensely focused on the customs of others, [female genital surgeries/mutilation, prevalence, health complications, sexuality]     

Care for infibulated women giving birth in Norway: an anthropological analysis of health workers' management of a medically and culturally unfamiliar issue

The focus of this article is on Norwegian health care workers' experience and management of birth care of women who have undergone infibulation. Because infibulation is the most extensive form of female genital cutting, infibulated women experience a higher risk of birth complications, and health workers generally experience delivery care for this group as challenging. Infibulated women, who come from recently arrived immigrant groups, are a challenge to the predominant Norwegian birth philosophy of "natural childbirth" and the positive evaluation of everything considered natural. The challenges relate to a mixture of technical know-how and a complex set of interpretations of central cultural elements of gender, nature, health, and gender equity. The findings suggest that a combination of taboo, silence, limited knowledge, and emotional difficulty along with a wish to be culture sensitive may at times prove counterproductive to giving the best help. Health care workers often seem to impose "imagined" cultural values on infibulated women, rather than clarifying them through personal communication.     

The work of Andrew Weil and Deepak Chopra--two holistic health/New Age gurus: a critique of the holistic health/New Age movements

Despite the popular roots of the holistic health/New Age movements, a growing number of biomedical physicians have become proponents of holistic health as well as New Age healing. Over the past two decades, Andrew Weil and Deepak Chopra, two biomedically trained physicians, have emerged as the visible and financially successful spokespersons of the movement. This article provides brief biographical sketches of Weil and Chopra and compares and contrasts their respective views on health, illness, healing, and health care. It also considers the response of various biomedical parties to these holistic health/New Age gurus who have attempted to integrate biomedicine and various alternative healing and metaphysical systems. Finally, this article argues that Weil and Chopra both epitomize the limitations of the holistic health/New Age movements, albeit in different ways.     

"Actually, I don't feel that bad": managing diabetes and the clinical encounter

A major issue for persons treating and managing adult-onset diabetes (NIDDM) is the "problem of compliance." I consider the clinical encounter in the overall context of diabetes management as a punctuated experience focused on the cultivation of an ideal self whose "technologies" and "ethics of self-care" mimic a capitalist logic that links self-discipline, productivity, and health. Both clinicians and their patients share and identify with many of the cultural referents and social values that circulate through medical advice and practice. However, using individual examples, I show how this shared logic can produce idiosyncratic regimes of self-care and clinical practice that result in hybrid medical practices incorporating differing objectives and emphases concerned with a tolerable present or an ideal future. Rather than organizing principles for research and medical practice, I suggest that medical compliance and noncompliance should be considered part of the rhetoric to be explained within the regimes of a pursuit of health.     

The emergence of integrative medicine in Australia: the growing interest of biomedicine and nursing in complementary medicine in a southern developed society

In this article, I examine the process by which some biomedical physicians and nurses in Australia have come to adopt various alternative therapies in their regimens of practice, largely in response to (1) the growing interest on the part of many Australians in what is generally called "complementary medicine", and (2) a recognition that biomedicine is not particularly effective in treating an array of chronic ailments. Some Australian biomedical physicians and nurses have come to embrace "integrative medicine," which purports to blend the best of biomedicine and complementary medicine, and have even created an Australasian Integrative Medical Association and established integrative medical training programs and centers. I argue that the adoption of alternative therapies and the development of integrative medicine on the part of Australian biomedical physicians and nurses constitute another national manifestation of the co-option of complementary and alternative medicine.     

A Qualitative Health Systems Effectiveness Analysis of the Prevention of Malaria in Pregnancy with Intermittent Preventive Treatment and Insecticide Treated Nets in Mali

Introduction

Delivery of intermittent preventive treatment with sulphadoxine-pyrimethamine to pregnant women (IPTp-SP) through antenatal clinic (ANC) in Mali is low, and whilst ANC delivery of insecticide treated nets (ITNs) is higher, coverage is still below national and international targets. The aim of this study was to explain quantitative data from a related study which identified ineffective processes in the delivery of these interventions in one district in Mali.

Methods

In-depth interviews were conducted with health workers at the national, regional, district and health facility levels on their perceptions of reasons for the ineffective processes identified in the quantitative study, and their reported practices. Themes were coded for each ineffective process, and within these a health systems lens was used. Content analysis was used for emergent themes within this framework. MindMaps were used to display the findings.

Results

Intervention specific factors for the ineffective delivery of IPTp-SP included misunderstanding of the upper limit of the gestational age at which SP could be given and side effects of SP. Incorrect practices had been recommended in training and supervision of health workers. Pregnant women who were ill on attendance at ANC were not consistently managed across health facilities. The most common reason for not offering women an ITN on their first ANC visit was if they were from outside the health facility catchment area. Broader health systems issues influencing the effectiveness of delivery of each of these interventions were also identified.

Conclusion

In this setting, intervention-specific factors resulted in the ineffective delivery of IPTp-SP. These relate to complex policy guidelines, lack of guidance on how to implement the guidelines, and the institutionalising of practices that undermine the national guidelines. Interventions may be implemented and show real gains in the shorter-term whilst waiting for broader health systems issues to be addressed.     

Going like Gangbusters: Transnational Tobacco Companies "Making a Killing" in South America

This article reports on the recent growth of transnational tobacco companies (TTCs) in South America. Although some scholarly attention has been directed toward such growth in Asia and eastern Europe, South America has also been targeted by the TTCs' aggressive expansionist practices in recent years. Fighting "Big Tobacco" is entirely different from combating most public health problems. Unlike cigarettes, most infectious diseases and maternal and child health problems never provide profits to transnational corporations and governments. Also, most public health problems (with alcohol being another notable exception) are not exacerbated by extensive advertising campaigns that promote the cause of the health problems. Supported by data gathered during three months of fieldwork in Ecuador, Peru, Chile, and Argentina in 1997, this article suggests that the TTCs' marketing strategies override cultural differences in the choices people make regarding smoking and health. Combining critical medical anthropology and public health, this article concludes that unless dramatic actions are taken, an avoidable outbreak of tobacco-related diseases will eventually reach epidemic proportions on the South American continent. It is also a "call to arms" for more medical anthropologists to investigate tobacco-related matters around the world.     

Conditions of life in the city: medicine and gendered relations in Maputo,Mozambique

How do material conditions, urban life strategies, and postcolonial medical infrastructures shape the practices of care available to patients and families in Maputo? How do global health interventions articulate with urban economies, colonial legacies, and gendered relations? Under what conditions is health made available in Mozambique's capital? This article explores these questions through the experiences of one young woman as she moves through clinical and city spaces and through changing familial and residential situations. Showing how health is shaped by gendered relations and material circumstances (or condições) as they are refracted through urban space, her experiences make clear that care both requires and creates complex material‐relational conditions rooted in clinic practice, urban forms, and gendered social and familial life. In the midst of complex medical regimes and rapidly changing urban spaces, these conditions constitute the ground on which women access medicine but also give rise to exclusions from forms of care produced by both biomedicine and social relations. Arguing for greater attention to the role of gender, urban space, economy, and exchange in theorizing health in situated urban and transnational spaces, this article advocates for accounts that go beyond biomedical and clinical framings of life, health, and well‐being and that centre relational accounts of life in the city.     

Reinscribing the birthing body: homebirth as ritual performance

In this article, I examine the clinical practices engaged in by U.S. homebirth midwives and their clients from the beginning of pregnancy through to the immediate postpartum period, deconstructing them for their symbolic and ritual content. Using data collected from open-ended, semistructured interviews and intensive participant-observation, I describe the roles ritual plays in the construction, performance, and maintenance of birth at home as a transgressive rite of passage. As midwives ritually elaborate approaches to care to capitalize on their semiotic power to transmit a set of counterhegemonic values to participants, they are attempting, quite self-consciously, to peel away the fictions of medicalized birthing care. Their goal: to expose strong and capable women who "grow" and birth babies outside the regulatory and self-regulatory processes naturalized by modern, technocratic obstetrics. Homebirth practices are, thus, not simply evidence-based care strategies. They are intentionally manipulated rituals of technocratic subversion designed to reinscribe pregnant bodies and to reterritorialize childbirth spaces (home) and authorities (midwives and mothers).     

Deadly inequality in the health care "safety net": uninsured ethnic minorities' struggle to live with life-threatening illnesses

Forty-three million Americans are uninsured. This article explores the difficulties people experience in seeking health care through the health care "safety net," which provides most of the health care that uninsured people receive, and critiques the gaps, inconsistencies, and failures of such care. In research with 176 African Americans and Latinos who had no health insurance, it was found that they delay seeking care because of cost, do without medications, have negative views of safety net health care, and experience discrimination. As a consequence of dissatisfaction with safety net care, avoidance of the health care system was commonplace. It is concluded that safety net health care facilitates the development of unhealthy practices, such as delays in seeking care. The inadequacy of safety net health care is thus injurious to people's health.     

Bound between care and control: Institutional contradictions and daily practices of healthcare for migrants in an irregular situation in Italy

On the books, the inclusiveness of the Italian framework regulating healthcare access for migrants is indisputable. However, we might wonder how access takes shape on the front-line of the healthcare system, particularly in times of increasingly hostile institutional and discursive environments. By focusing on Italian migration and healthcare policies and the practices of health workers during their encounters with migrants in an irregular situation, this contribution analyses how health workers deal with institutional tensions in the field and how these, in turn, shape their narratives and actions. It suggests that individual positioning plays a major role in favouring the adoption of discretional practices of care or control. Nonetheless, practices are also mediated by the wider institutional and discursive landscape, which has been exponentially characterized by a tension between a medical-humanitarian logic that legitimates providing healthcare to vulnerable migrants, and a control-oriented logic targeting immigration and health expenditure.