Abstract
In this study, I examine Indigenous women’s autonomy and reproductive rights within Mexico’s Prospera program. Prospera gave women living in poverty bimonthly cash stipends for complying with requirements argued to improve the health and welfare of their families, including attending regular appointments at the clinic. Although hailed as successful, Mexico’s new administration recently eliminated the health care component, citing various abuses. Some policy experts argue that these claims are unfounded and have questioned how Mexico will now address the health care needs of marginalized populations. Drawing on more than 2 years of fieldwork (2012-2014) in a Mayan community in Chiapas, I present evidence of abusive practices related to reproductive health care based on direct observations and audio-recordings of clinical interactions and program operations in IMSS-Prospera. Furthermore, I show how the reproductive habitus that supported these actions was shaped by long-standing institutional habits and sociocultural factors that need to be directly addressed in present reforms.
Prospera (formerly Progresa/Oportunidades) 1 was one of the first and most successful of the conditional cash transfer programs (CCTs) that continue to be popular in development policy circles. By making financial assistance contingent on compliance with requirements in the areas of health care, nutrition, and education, Prospera aimed to alleviate poverty while promoting long-term national development and economic growth (Levy, 2006). Numerous studies demonstrated positive effects on a variety of outcomes, from educational attainment to gains on health measures (Escobar Latapí & González de la Rocha, 2009; Fernald, Gertler, & Neufeld, 2008, 2009; Fiszbein et al., 2009; Skoufias, 2005), leading Prospera to serve as a model for similar programs in more than 60 countries (Bastagli et al., 2016). After operating through four successive administrations, Mexico’s new administration recently eliminated the health care component of Prospera, claiming that, among other abuses, it created an atmosphere where beneficiaries could be extorted (Enciso, 2019; Russell, 2019). Some policy experts have been critical of these actions, citing a lack of evidence of abusive practices and questioning how Mexico will now meet the health care needs of marginalized populations (Gómez Hermosillo, 2019; Gutiérrez, 2019). In this study, I use an ethnographic approach to examine Indigenous women’s agency in Prospera in the area of reproductive health care in a Mayan community in the state of Chiapas, particularly in clinics run by the Mexican Social Security Institute (IMSS). Although several studies have examined Prospera’s effect on women’s empowerment more generally using surveys, interviews, or focus groups (e.g., Adato & Mindek, 2000), few have examined empowerment with respect to reproductive health care or taken an ethnographic approach, particularly in Indigenous communities that have historically been targeted by government efforts to control women’s fertility (see Smith-Oka, 2009, 2013, for exceptions).
Although I do not endorse or reject specific policy decisions, in emphasizing agency, I align myself with a health and human rights perspective which prioritizes the ability of individuals to “fully exercise their reproductive and sexual rights” (J. L. Jacobson, 2000, p. 22). This perspective has long been incorporated into the Mexican constitution, but actual practice has diverged from these ideals. Even recent recommendations for improving reproductive health care for Indigenous women have continued to emphasize the collection of statistics on the use of family planning and reproductive health care services without adequate consideration of how these services are conducted or the means by which such statistics are produced (IMSS-Prospera, 2017). Following Ahearn (2001, p. 112), I define agency as “the socioculturally mediated capacity to act,” which is intimately related to women’s empowerment, or the process through which women who have been denied agency in making strategic life choices acquire it (Kabeer, 1999). Women’s empowerment, in turn, is deeply entwined with their reproductive health and rights. Numerous studies have found that measures of women’s empowerment are associated with increased contraceptive use and lower fertility rates which may lead to greater participation outside the domestic sphere (Blanc, 2001; Malhotra, Schuler, & Boender, 2002). Reproduction, however, has also been argued to be an important problem space for examining Foucauldian notions of biopolitics and biopower, referring to the mechanisms that governments use to manage the vital characteristics of populations and discipline citizens, potentially restricting their agency and autonomy. As Rabinow and Rose (2006) note, reproduction includes an array of connections “between the individual and the collective, the technological and the political, the legal and the ethical” making it “a biopolitical space par excellence” (p. 208).
Given the socioculturally mediated nature of agency, I also draw on Smith-Oka’s (2012) notion of a “reproductive habitus” (p. 2276), entrenched interactional patterns between people and structures that create “modes of living the reproductive body, bodily practices, and the creation of new subjects.” Using this transactional approach, in this study I examine Indigenous women’s agency in reproductive health care within the complex dynamic between program beneficiaries, health care workers, and the health care institutions charged with implementing Prospera. This dynamic, in turn, is embedded in a broader sociocultural and historical context in which Indigenous women’s rights have routinely been violated to further national development goals. I thus begin with an overview of Mexico’s history of forcibly controlling poor and Indigenous women’s fertility, particularly within IMSS. I next describe the health care component of Prospera, including the arguments purporting and critiquing its effects on women’s empowerment. I then present findings drawn from 2 years of fieldwork that illustrate a range of abusive practices at the institutional and interpersonal levels, from the public monitoring and shaming of women’s fertility and reproductive choices to the outright violation of their bodily autonomy. I end with a discussion of the lessons to be learned from Prospera, including suggestions for present reforms.
Family Planning in Mexico From the 1970s to Prospera
Efforts to promote family planning in Mexico, which began in the 1970s, aimed to guarantee citizens the right to decide freely on the number and spacing of their children. These aims were quickly overshadowed, however, by demographic goals for population control leading to an interventionist style particularly in rural regions. Differences between Mexico’s two main public health care institutions, the Secretariat of Health (SSA) and IMSS, were present from the start. While the SSA relied on the existing infrastructure, IMSS constructed more than 3,000 rural health clinics connected to regional hospitals (Potter, 1999). A tight-knit hierarchy, with frequent supervisory visits and regional and national meetings, helped socialize IMSS workers to the guidelines and priorities of the institution. This system was so effective that, in a 1984 study, health care workers in IMSS gave near-identical responses when asked about best practices in family planning, including the suitability of the intrauterine device (IUD) and female surgical sterilization postpartum (Potter, 1999). Both institutions early-on established method-specific targets for contraceptive use, but especially in IMSS priority was given to the IUD and female sterilization as these were considered the most effective for limiting fertility. Postpartum acceptance was promoted, particularly in Indigenous regions due to the early age of first intercourse (many Indigenous women still marry by mid-adolescence, particularly in rural areas) and the comparatively late uptake of contraceptive use (Kirsch & Cedeño, 1999). So strong were the pressures in IMSS that job stability and financial incentives were linked to quota fulfillment (Kirsch & Cedeño, 1999).
International development conferences in the mid-1990s called for a greater range of available contraceptive methods and reproductive health services. In response, Mexico established a set of Normative Guidelines, later enshrined in its Constitution, that emphasized freedom of choice and quality of care over meeting method-specific targets. Actual practice, however, continued to diverge from official guidelines (Potter, 1999). For example, although the guidelines stressed the importance of informed consent, a 1999 study of hospitals in Chiapas (a state with a large Indigenous population and the site of this study) found they had neither completed nor blank consent forms for female surgical sterilization despite a postpartum sterilization rate of 30% (Kirsch & Cedeño, 1999). Women reported that they were pressured to consent to sterilization or an IUD during the most painful stages of labor and were informed only afterward if an IUD was inserted for a “medical indication” (Potter, 1999). These tactics were effective: By 1995, the IUD and female surgical sterilization had become the predominant forms of birth control in Mexico while hormonal methods correspondingly plummeted (Potter, 1999). Postpartum IUD insertions more than doubled from 1987 to 2014, with the majority occurring in public hospitals, especially those run by IMSS (Potter, Hubert, & White, 2017). Prospera (then Progresa) was launched in 1997 in this context. Although promoting family planning was never an explicit goal, the program provided new means to achieve these ends (Feldman, Zaslavsky, Ezzati, Peterson, & Mitchell, 2009).
Prospera, Women’s Empowerment and Reproductive Rights
Prospera provided bimonthly cash stipends to female heads of households designated as program beneficiaries, or titulares. Women were targeted as they were considered more likely than men to spend the funds on their children’s welfare (Adato, de la Birere, Mindek, & Quisumbing, 2000). In exchange for this assistance, titulares were required to complete requirements targeting the health of their families and the education and nutrition of their children. The health care component was administered through clinics run by either the SSA or IMSS. There were important differences, however, in the manner in which each institution implemented the program with respect to reproductive health care which mirrored the history of such practices in each institution. Among common requirements, all members of a titulare’s household attended biannual checkups, pregnant women attended regular prenatal controls, and children aged less than 5 years were brought to the clinic for periodic height and weight checks. Titulares were also required to attend monthly health care talks known as pláticas. If a woman did not complete a requirement, it was marked as a failure, or falta, on her record, and her next benefit was reduced by half. After four faltas in a row or six within a 12-month period, she was dropped indefinitely from the program (Secretaría de Desarrollo Social [SEDESOL], 2016).
That the program gave benefits directly to women was argued to increase women’s empowerment by improving their bargaining position within households (Adato et al., 2000; Behrman & Skoufias, 2006; Skoufias, 2005). Surveys, for example, suggest that titulares had greater independence in purchasing household goods and received greater recognition of the importance of their household roles (Adato et al., 2000; Escobar Latapí & González de la Rocha, 2009). Little evidence has been found, however, of empowerment in other domains. Rather, critics argued that the program paid women to be “good mothers” as defined by the interests of the state (Agudo Sanchíz, 2010; Molyneux, 2006). Women, according to this analysis, were treated as the means of production of a healthier next generation that would be better prepared to enter the labor market, while doing little to improve opportunities for the women themselves. In fact, studies found that women sometimes needed to drop jobs to fulfill program requirements (Escobar Latapí & González de la Rocha, 2009). The educational component, which will continue under present reforms, gave titulares funds for their children’s school attendance and provided 10% higher stipends for girls than for boys starting in the seventh grade. Nevertheless, girls who benefited in their educational attainment were often channeled back into the program as titulares themselves for lack of economic opportunities and persisting gender inequalities, especially in Indigenous regions (Gil-Garcia, 2016).
Importantly, empowerment has multiple dimensions including participation in the public domain and beliefs about one’s own independence, capabilities, and rights (Adato & Mindek, 2000; Kabeer, 1999). In the health care setting, this includes the ability to define one’s own needs and goals and direct the agenda of clinical interactions. Rather than empowering women in this domain, critics have argued that Prospera’s conditionalities provided a mechanism for controlling the most intimate aspects of their lives. From the program’s inception, titulares reported that health care workers threatened to withhold benefits if they did not accept certain procedures including Pap smears, IUD insertions, and surgical sterilization (Kirsch & Cedeño, 1999). Even where such threats were not explicit, that health care workers were charged with reporting titulares’ attendance was argued to increase the likelihood that any medical advice would be perceived as a program mandate (Smith-Oka, 2009). Such risks were arguably greater in Indigenous communities where inherent imbalances between practitioners and patients are already amplified by sociocultural and linguistic divides (Adato, Roopnaraine, & Becker, 2011). Smith-Oka (2009), for example, in interviews with Nahua titulares in the state of Veracruz, found they felt forced to comply with doctors’ recommendations for family planning. Adato and colleagues (2011), in focus groups in the states of Guerrero, Michoacán, and Veracruz, found few expressions of overt coercion. Nevertheless, some participants did state that birth control had been presented as a program requirement, and doctors’ recommendations were found to influence women’s decisions about contraceptive use, raising the question of exactly how family planning recommendations were communicated.
Critics, as noted, have pointed to the coercive lever of the program’s conditionalities. Others, citing data from other contexts (e.g., Malhotra et al., 2002, cited in Feldman et al., 2009), have argued that the program might indirectly increase contraceptive use through its effect on women’s autonomy in household decision making. In testing this hypothesis, Feldman et al. (2009) confirmed that the program had positive effects on contraceptive use and on women’s autonomy in household decision making, but the latter did not mediate the former. Baseline levels of autonomy did, however, have a moderating effect: Differences between titulares and controls in contraceptive use were found only among participants with the lowest initial household autonomy levels. Feldman and colleagues speculated that this may have been due to these women being introduced to resources that had not previously been available to them. A possibility that they did not consider is that women with the lowest initial household autonomy—who were more likely to be poor, Indigenous, and have low levels of literacy and education—were more subjected and susceptible to the abusive practices outlined in the previous section.
In support of this, a recent report by the United Nations Committee on the Elimination of Discrimination against Women (CEDAW) found that of the 8.7 million women in Mexico who gave birth between 2011 and 2016, 33.4% reported suffering mistreatment by medical professionals. The most frequent abuses included yelling or scolding and pressuring the women to accept contraception or sterilization. Of those who suffered some type of abuse during childbirth, 26% spoke an Indigenous language or identified as Indigenous, and 40% were treated in IMSS (CEDAW, 2018). The connection between such practices and social assistance programs like Prospera, however, was not explored.
Setting and Methods
In this study, I examine Indigenous women’s agency in reproductive health care within Prospera using direct observations and audio-recordings of clinical interactions and program operations, supplemented by key-informant interviews, in a Mayan municipality in Chiapas. Given the small number of clinics, I do not name the municipality, and all names used are pseudonyms. The municipality, however, is typical of Indigenous communities in the region. Most of the approximately 40,000 residents are Tseltal 2 Mayans who practice subsistence farming in one of the 60 or so hamlet-like subdivisions, or parajes, located throughout the highland terrain. The municipal center has a small population of Spanish-speaking mestizos, 3 and most Indigenous children now acquire Spanish at school. Tseltal, however, is the primary language of the community and typically the only language spoken in Indigenous homes. Many adults, especially women, have little formal schooling and limited Spanish language and literacy skills.
There are nine clinics in the municipality, four run by the SSA and five by IMSS, with each serving from two to nine parajes. The municipal center is the only area to have one clinic from each institution. Individuals, however, are assigned to a clinic based on residence and may not attend another except for an emergency. The SSA clinic in the center has a full staff that rotates daytime, evening, and Saturday shifts. All other clinics are staffed by a single doctor and one or two nurses and operate daytimes on weekdays only. The IMSS clinics, known as Rural Medical Units (Unidades Médicas Rurales or UMRs), were particularly under-resourced and needed repairs, including out-of-order toilets, peeling paint, and moldy walls. Itandehui Saavedra, Berenzon, and Glavan (2017), describing a similar state of neglect in public health centers in Mexico City, noted the normalization of such conditions for free or low-cost health services. In the clinics where I observed, for example, community members had to purchase folders for their own files and were pressured to “cooperate” funds for supplies. Titulares were required to assist with cleaning and maintenance (the faena), which was promoted as a civic duty and a sign of responsibility for one’s health.
The examples that I will present are drawn from a 2-year ethnographic study of Prospera conducted between August 2012 and August 2014, with 1-month follow-up visits each summer from 2015 to 2017, and a 2-week visit in March 2019. Although I am from the United States and of non-Mexican descent, I had conducted research in the municipality for 7 years prior to undertaking this study. I speak fluent Spanish and advanced Tseltal and had observed and participated in many aspects of community life. This facilitated building trust and rapport with participants and helped me to contextualize my observations. All procedures had institutional review board (IRB) approval. 4 Written consent to work in the clinics was granted by the jurisdictional coordinator of each institution and then by individual health workers. Written consent was obtained from community leaders in each paraje and then orally from individuals at each clinic. Oral consent was used as many participants had limited literacy in either Spanish or Tseltal. For observations of meetings and workshops, written consent was first obtained from the event leaders. I then requested permission from participants at a group meeting who discussed it among themselves until they reached consensus, in line with the system of participatory democracy known as usos y costumbres that is practiced in the community. Apart from the health care workers and community leaders, participants’ names were not collected or recorded. Participants were not given any incentives. They were told that their participation was voluntary and that they could withdraw consent at any time.
Sampling was done on a targeted and convenience basis. In total, I observed in five of the nine government-run clinics, two of the SSA and three of IMSS. At each clinic, I targeted a range of required and nonrequired consultations, including prenatal controls and consultations for family planning. Participants were then recruited from those present on the days I observed. Depending on the conditions, in some clinics, I directly observed as well as audio-recorded consultations. In others, I audio-recorded but did not observe the consultations, leaving me free to interview patients before or after their consultation. Interviews took place in a private room at the clinic when available without health care workers present or in a quiet and private area outside of the clinic. Questions focused on participants’ experiences and attitudes toward the clinic and Prospera, including reproductive health care. I also interviewed health care workers at each clinic regarding their relationship with the community, their experiences with Prospera, and their practices regarding family planning and informed consent. In addition to consultations, I observed and recorded the health care pláticas, required household observations, community meetings, and general program operations. In addition to my work in the government clinics, I observed a group of independent community health promotors and a traditional healer, which provided a broad perspective on health and health care in the region. Recordings in Tseltal were transcribed and then translated into Spanish by native Tseltal-speaking bilingual assistants. Where possible, I worked side-by-side with the translator to ask clarifying questions. Spanish recordings were transcribed by me or a native Spanish-speaking assistant. I also kept fieldnotes and produced a series of analytic memos while in the field. Transcripts and fieldnotes were analyzed using open and then focused coding to identify major themes and practices related to women’s agency in reproductive health care and to compare across contexts (Emerson, Fretz, & Shaw, 1995).
In the present analysis, I focus exclusively on the three IMSS clinics where I observed the most egregious practices. As one example, while health care workers in the SSA rotated through the set of available topics for the pláticas, workers in IMSS focused exclusively on family planning. As one doctor reflected, this was the “most important” as it was the priority of IMSS. In the following sections, I discuss the most common themes and practices drawn from more than 6 months and 95 recorded hours of observations in the three IMSS clinics. These include interviews with the doctor and one nurse from each clinic, interviews with 30 titulares, and more than 120 consultations. I have organized the themes into two overlapping levels, the institutional and the interpersonal. I follow this with two case studies that illustrate how these levels interacted with one another and with the sociocultural context to create a reproductive habitus that supported serious violations of women’s autonomy and reproductive rights.
Findings
The Institutional Level: Reproductive Health Care in IMSS-Prospera
A hierarchy of surveillance
Pressure on women to accept family planning was embedded in the organizational structure of the program, which resembled the tight-knit hierarchy described as characterizing IMSS in the past (Potter, 1999). In addition to frequent regional meetings for health care workers, a regional health promotor or PAC (Promotor de Acción Comunitaria) gave workshops on family planning in the parajes and trained community health workers. These included asistentes de salud (elected community members, almost all male, who served as liaisons with the clinic) and traditional parteras or midwives who were registered with the clinic. Although not required, I observed considerable pressure on parteras to register. Titulares were told they were not allowed to use unregistered parteras, and on one occasion, I saw a doctor severely berate a woman for doing so. In this way, the program’s conditionalities could be used to control traditional health workers. Parteras and asistentes were paid a small stipend by IMSS and formed part of the Red Comunitaria, a “Community Network” with the express goal of reducing maternal mortality by creating a chain of assistance for rural women. In practice, this arguably also served as a form of structural surveillance and control. Asistentes and parteras were trained and pressured to report pregnant women to the clinic and to encourage them to accept contraception postpartum. Responsibility for preventing maternal mortality therefore started on the bottom of the hierarchy with community health workers, while pressure was exerted from the top down.
For example, during a meeting with her asistentes and parteras, Doctora Mari, who spoke Tseltal, chastised them for reporting no new acceptors for family planning, particularly female surgical sterilization (bilateral tubal occlusion [BTO]). The pressure “goes by chain,” the doctora explained, from the jurisdictional coordinator to the regional supervisor to her, each “pulls the ear” of the next. “I come to you, and what do I tell you?” she asked rhetorically. “I pull the ears of my asistentes.” If she were to respond to her supervisors as they were responding to her, she noted, she would be fired: What do the parteras say? “Ay! There are none.” “Ay! There is no one that wants it [sterilization].” “Ay! They say they want more children.” [the parteras laugh] . . . If I go down there, to San Cristóbal, “Nooo, it’s that they don’t want it.” “Nooo, it’s that they don’t want it.” “Nooo, it’s that they say they don’t want it.” Eh? Well, they say, “You know what, doctora? Get your things, get your bag, and go.” Yes? They don’t want- they don’t want us to say that there are none, yes? They don’t want this.
Quotas, incentives, and punishments
All of the doctors I spoke with described the intense pressure they experienced in IMSS to “produce” in the area of family planning, hearkening back to the system of incentives attributed to IMSS in the past (Kirsch & Cedeño, 1999). Productivity was based on their ability to meet method-specific quotas set for each clinic, with priority given to the IUD and BTO. Those deemed “unproductive” were reportedly sent to the least desirable locations to work. One doctor described a system of points given to clinical and community health workers alike for each new acceptor they convinced, with more points given for the IUD and BTO based on their respective quotas, which translated into additional resources for the region. Several women who I interviewed mentioned rumors that doctors received bonuses for each woman they recruited for sterilization. Although I was not able to verify this, Erviti, Sosa Sánchez, and Castro (2010, p. 783) reported that the male doctors they interviewed in central Mexico regarding their contraceptive counseling practices mentioned the “continuous supervision of goal achievement” for female contraception and “even monetary compensation.” This compensation, they reported, was tied to internal labor regulations granting higher compensation for medical interventions classified as carrying greater professional risk. This may have been the source of community rumors or they may have been a carry-over from IMSS’s past; nevertheless, such rumors reflected community awareness of the pressure within IMSS to promote these methods.
The following example illustrates how these points were discussed within the Red Comunitaria. During the meeting with her asistentes and parteras, Doctora Mari noted that only one woman had gone for sterilization the previous month and had done so of her own volition; therefore, no one could take credit for her on their account. The doctora explained: There is only one for the BTO. One and this because alone- alone she came with her husband. The asistente didn’t tell me, nor did I convince her. They came alone. Because that’s how it’s going to be, on your papers, on your reports. If Juanito [an asistente] brings me two patients for March, they are going to be on Juanito’s account, yes? It won’t be me that convinced them, nor the parteras, nor no one, yes? It is going to remain forever as the asistente’s.
Although she did not mention any rewards, Doctora Mari did warn of punishment if a woman were to die from pregnancy-related complications: “[The PAC] said, if a pregnant woman dies, the doctor will go to prison. The asistente comes, the partera comes, you hear, they will go to prison.”
Public monitoring and labeling women according to reproductive “risk.”
Women’s fertility and contraceptive use were publicly monitored, and they were praised or chastised for their reproductive choices. For example, the method-specific quotas for each clinic were determined based on an annual census of each paraje the clinic served. Women waited for hours at these events, packed into the local primary school, often accompanied by crying infants or children. When called, they were questioned by health care workers at the front of the room: How many children did they have? What was their method of contraception? If they were not using any, why? Women of childbearing age (15-49 years) were divided into two groups: Group 1, labeled “high risk,” used no contraception or a short-acting method. Group 2, “low risk,” were post-menopausal or used a “definitive” method: either the IUD or sterilization. Women’s status was often publicly discussed and displayed. At one clinic before a plática, the nurse asked the women to form three lines to collect their attendance cards: one for women who were sterilized, a second for those with an IUD, and a third for everyone else. The women complied, chatting in line, illustrating the normalization of such public displays. The asistentes kept a register of new acceptors which they relayed each month to the PAC. At the end of one workshop that I observed, the asistente submitted a list of 11 new entrants to Group 2, most of whom had been sterilized. The PAC beamed, “For me this is excellent, those that have changed to this definitive method.” He congratulated the women by name, effusing, “How good! Congratulations now. Group two, how good!” noting that the “advantage” was that they would no longer have to attend the monthly workshops required of those in Group 1.
Extending the clinic’s reach
An important component of Prospera was mandatory but unannounced household visits to check for compliance with program mandates such as boiling drinking water and using a latrine. These were conducted by an elected committee of women from among the titulares in each community and separately by the PAC, accompanied by an asistente to translate. Those not in compliance received a warning and then a falta. I accompanied the PAC on six of these visits, during which the women were asked if they were family planning 5 and whether anyone in their household was pregnant. Titulares were told that all pregnant women in their household were required to report to the clinic regardless of whether they were also titulares, thereby extending the clinic’s reach. At one house, the PAC informed a young woman who was 7 months pregnant and had not yet been to the clinic that she had to go the next day even though she was not in Prospera. If she did not go, her mother-in-law, whom she lived with and who did have Prospera, would receive a falta. The PAC explained, using the third-person diminutive, “La embarazadita [the little pregnant lady] has to go tomorrow.” The asistente who translated added, “This is what they told us in the meeting. It is very strict, it’s that, the names of the women are well-recorded, the women who are pregnant. . . . They are well-watched, in truth, they are searched for.” A neighbor who was present then volunteered that her daughter-in-law who lived with her was also pregnant, noting that she had heard that they can “scold” you if you do not tell.
The Interpersonal Level: Practitioner–Beneficiary Relations
Use of conditionalities and faltas as threats
In interviews with health care workers, some admitted to using the faltas as threats. The threatening nature of the faltas was noted by Doña Jovita, the nurse in the municipal center, who explained that Prospera had helped reduce pregnancy-related complications “because we are frightening them . . . If you don’t come [to your appointment] we are going to put a falta, and you will not get your money. And this is how they are coming—how the women are coming.” She noted that, with Prospera, they had been able to “demand more”
6
from the women: This money? We demand them, you are going to listen to this, what we are going to say, because if you do not listen to us, if you do not understand what we are going to say? It is going to be a falta.
The nurse admitted that it was a “falta of lies” or false falta. Nevertheless, it allowed her to keep women who she felt had not paid attention, for example, those who could not answer her questions, and make them stay to hear the plática again, regardless of the reasons the women gave. The nurse explained: So [the women] say, “ah, it’s that my child was crying,” “it’s that I took my child to urinate”—No no no no no no. It’s that here, you are going to pay attention a little. If you had told me what you heard? I would mark your attendance, but since you did not hear anything I told you? I tell them, I tell them, I am going to put a falta. . . . That’s when they pay attention, in the second plática I give. But I don’t give them a falta. No, I don’t give them a falta [laughs].
Doña Jovita, a mestiza woman in her mid-40s, was from the community and spoke good Tseltal. She had worked in the clinic for more than 20 years, beginning as a translator when clinics desperately needed individuals who spoke an Indigenous language and later earning a degree as a nurse technician. Most of her training was therefore from IMSS. A caring individual, she enjoyed a good rapport with the women, many of whom she had known for years. Nurse Jovita was cognizant that she could not force anyone to accept family planning, and she knew the women desperately needed the money from Prospera. She explained that it was not until they missed an appointment or did not attend a plática that she gave them a falta, that is, “once the woman no longer—once she becomes. . . rebellious.” 7 Nevertheless, at one talk that I observed, the PAC who was to give the talk did not arrive, leaving Jovita to explain what the meeting was to have been about. She explained that the women would be divided for monthly workshops based on their age and contraceptive use to warn them of the dangers of pregnancy past age 35, which she said would no longer be “allowed” without “permission.” When one woman asked what would happen if they did, the nurse replied that they would be dropped from the program, “baja directa.”
In interviews, some women also expressed that the program was “built on fear”, 8 as one woman put it, as they feared getting a falta if they did not comply. When asked if they would still come to the clinic if the program ended, the same woman replied that they might come for medicine, but “It will not be that they obey the talk.” The few women who mentioned direct threats were cognizant that they were only threats. Nevertheless, their responses revealed how such threats were used to shape the women’s behaviors. One woman noted, “The doctor alone says, ‘I will give you a falta,’” however, “they will not give you a falta quickly if you are able to take care of your children. If you can’t, there is where, ‘get family planning.’” Hence, as long as the women were perceived to be “good mothers” and were not “rebellious,” they would not be threatened. The same woman explained that although others might think there was pressure in the program, she did not because “if they oblige us, it is for our own good,” echoing a refrain that I heard from titulares and health care workers alike. This response may have been due to me being an outsider; nevertheless, such contradictions suggest a normalization of program pressures and an internalization of the program discourse (cf. Torres-Pereda, Heredia-Pi, Ibáñez-Cuevas, & Ávila-Burgos, 2019).
Use of humor, mocking, and humiliation
Perhaps to cope with institutional pressures and a reluctant population, health care workers often used humor to mock the women’s fertility and reproductive choices. Although such humor may have been well-intentioned, given their asymmetrical relationship, it arguably helped appease resistance among beneficiaries while reinforcing health care workers’ authority and control (cf. Smith-Oka, 2013). In the following example, Doctora Mari provides an impromptu talk to about 100 women gathered for an aforementioned census. She notes that the program has been operating for many years, yet there are still women who do not obey its mandates for family planning. 9 After asking the women what they had learned in the program, she mocks one woman’s response before publicly questioning her fertility and reproductive choices:
And what have you learned? What have you learned? What do you think in your heads? Are you doing what the- um, the order of [Prospera]?
[long and drawn out, as if tired] Yeeeesssss.
[mockingly] Ah? She says “yes.”
[The other women laugh.]
How many children do you have in all?
Four.
Four- four children. And what do you say? Did you have the operation?
Uh-uhn [no]
How- how- how did you block yourself?
The- the apparatus [IUD]
The apparatus. Fine. And now- umm- do you still menstruate every month?
Doctora Mari’s mocking elicits laughter from the other women, aligning them with the doctora and defusing the tension in the woman’s response. In private, such chiding was sometimes far less humorous.
Hostility and prejudice
The most hostile of the health care workers that I observed was Doctora Laura in the municipal center, a mestiza woman in her mid-30s who made no effort to hide her scorn for the Indigenous women she reluctantly attended. During the time that I worked there, for example, she suspended all consultations other than those required by Prospera to complete paperwork for an upcoming certification—the only doctor who I observed to do so. In the following example, she scolds a pregnant woman during a required prenatal control for not attending her previous appointment. The woman explains in a soft voice that she had arrived at 8:30 a.m., but the nurse told her the doctora would not take any more patients. Women had to show up before the clinic opened on the day of their appointment to obtain a ticket, or ficha to reserve their spot, and then spent the day waiting their turn. If a woman came late, she received a falta instead. “Eeeeeee,” Doctora Laura angrily sighed, “You should be responsible for your panza [belly]. I make myself responsible for you people, and you cannot be responsible for your own panza,” adding with scorn, “that was for your desire . . . and pleasure.”
Perhaps ironically, the pressure placed on health care workers in IMSS may amplify resentment and help perpetuate stereotypes of poor and Indigenous women as hyperfertile and incapable of self-control. They reproduced “like rabbits,” Doctora Laura later explained to me. For example, health care workers were responsible for going to the homes of pregnant women who did not attend their prenatal control to try to convince them to come, prompting the doctor to rebuke the woman in a hostile tone: I do you the favor of seeing you, but this is not my community. I told you when I accepted [the position]. I accept, but you are going to make yourselves responsible, because I don’t want to go looking for you.
Case Study 1: Strategic Out-Stocks of Contraceptive Methods
This first case illustrates how the interpersonal and institutional levels interacted to enact and justify one of the more aggressive violations I witnessed: what appeared to be purposeful outstocks of short-acting contraceptive methods, especially the hormonal injection which many women preferred. When I asked Nurse Jovita what methods were available, she pointed to a poster on the clinic wall displaying a range of methods and recited the official list. During my 2 years of fieldwork, however, no hormonal methods were available at that clinic other than a small number of implants given to women who for medical reasons could not take an IUD. Similarly, doctors at the other IMSS clinics had a small stash of hormonal methods to give at their discretion. Doctora Laura also initially stated that all methods were available. When I commented that I had heard the nurse tell women there were no hormonal injections, she responded sarcastically, “Yeeesss, they have to buy it,” meaning the women had to purchase the injection from a private provider or pharmacy. With prices ranging from US$180 to US$200 pesos per injection (US$13-US$15 at the time), the cost was prohibitive. The doctora cited a mismanagement of finances at IMSS which left no budget for the injection. The nurse, she explained, was the first “tope,” or speed bump, in convincing the women to switch to a definitive method. “In the end,” she explained, “they have to accept because they don’t want to spend.”
The first tope
At the interpersonal level, Nurse Jovita was indeed the first tope. She first informed the women that there was no injection and then channeled them toward a “definitive” method. As the following encounter illustrates, “there is no injection,” delivered in a sing-song cadence in Tseltal, could be heard like a mantra throughout the interaction and indeed the day.
[In a hushed voice] Jovita, there is also something I want to ask you. I want to ask you for medicine, for the injection.
But there is none of the- injection.
Ah, there is none?
[Italics to indicate a sing-song voice] There is none. You will have to buy it. Because there isn’t any now.
Ah, there is none?
There is none.
I thought that perhaps there was some.
There is none.
Ah- . . .
There is none.
The nurse then asks, “Why don’t you do it [sterilization] for once and for all?” She notes that the woman already has enough children: “What more do you want? Boys? You already have. Girls? You already have.” With no other options, the woman agrees to accept an IUD. Jovita compliments her on her “choice”: “It is good that you accepted, because it is better- well, I say the apparatus [IUD] is better.” Besides, she reiterates, “There isn’t any [injection] anymore.” In perhaps a final bid, the woman reflects dejectedly, “I thought perhaps there was some.” “There is none,” repeats the nurse, “There is none.”
A sing-song tone, along with diminutive or familiar forms of address (e.g., “la embarazadita”), may express condescension in health care encounters, a form of dignity violation (N. Jacobson, 2009). Responding to another woman, the nurse exclaims in a similar tone, “Ay, madre! But it’s that, the injection, there is none.” She notes that the injection will make the woman sick, stating that some women get headaches and have their period twice a month. In contrast, she assures the woman that the BTO is very small: “Let’s say they do it today. Tomorrow, what do you do? You walk, you walk, you walk. The second day? You can wash your dishes; you sweep your house. The third day, you can make your tortillas.” She admits that the IUD may cause inflammation but states that this is “normal.” No other side effects or risks are discussed. When the woman still does not agree to either of these methods, the nurse tells her to “think about it,” because in any case the “Injection right now, there is none.”
The bottom line
When I asked Jovita why there was no injection, she said that all she knew was that it had not come for months and she had no idea when it would arrive. Speaking in Tseltal to a group of titulares gathered for a workshop, however, she revealed a more purposeful strategy by IMSS with the goal that they accept an IUD or sterilization. Her explanation, which was embedded in a discourse of preventing maternal mortality, spanned both economic and punitive motivations. Nurse Jovita first scolded the women for not complying with the program’s recommendations for family planning, illustrating the not-so-subtle way that recommendations could be communicated as mandates. “Because it is already five years that they have been telling you,” she explained. “The people do not obey. They do not want the operation.” From now on, therefore, she said, they would have only two methods available, the IUD and the BTO: “Injection, already there is none- not the injection, nor the pill. Only the IUD and the operation. Already- nothing more,” nurse Jovita remarked, “nothing more.”
The nurse explained that the program leaders, the “ajwalil” in Tseltal, would no longer allow the women even 1 month after giving birth before being given an IUD or surgically sterilized. The term ajwalil, meaning “owner,” “boss,” or “lord” in Tseltal, is often used to denote the government or those in power. It both abstracts and personifies the program, like an angry father punishing the women for their disobedience. Nurse Jovita explained: Now what does the ajwalil say? Will they have the injection? No- now- there is no injection. . . . One week- when it is already eight days from when the baby is born, they will get the IUD. . . . Because they take the injection, they want the injection- [mockingly] “Injection injection injection injection.” It is finished- it is no more.
She noted that the doctors had asked for volunteers to be sterilized. Many women said they would go, but then no one came, prompting the ajwalil to retaliate. “Since they saw that [the women] were lying, now they say, we will not heed their words either. ‘They want the injection? Well, where will they get the injection if there is none?’” This is not to say that budgetary constraints did not also play a role. The nurse noted that the ajwalil would like to remove women who had been in the program a long time so that more could enter. “Since they can’t erase them,” Jovita told the women, “what do they say? They say that they want them to be operated,” thereby cutting the costs of continued contraception.
Perhaps to placate the women, or to separate herself from the ajwalil, the nurse then states that she will try to get some injections from a neighboring municipality, but warns that over there, a car comes once a week and takes as many as 15 women to be sterilized in a day. She explained, “I don’t know- I don’t know what they say. If under threat they do it, but there they leave- they leave.” Perhaps foreshadowing what will happen if the women continue to disobey, Nurse Jovita reiterates, “Here what do they want? ‘Injection, injection, injection.’ Now the injection, yes? It will no longer come.”
Case Study 2: The Nonconsensual Insertion of an IUD
This second case illustrates how institutional pressures interacted with the local sociocultural context to create a reproductive habitus that supported the outright violation of women’s bodily autonomy. It is about a half-hour drive from the municipal center to the clinic in the paraje of Yaxalte. The climate warms and vegetation changes as one travels downhill. Doctora Mari, who by her own account is “media gritona,” or half-loudmouthed, invites me to eat breakfast there each day—cooked vegetables and tortillas she brings from home. The doctora talks freely, pausing only to encourage to me eat. Born to a Tseltal mother and a Tsotsil 10 father, Doctora Mari speaks a mix of the languages that allows her to communicate directly with the community. A chance opportunity led to her study medicine at the UNAM in Mexico City (National Autonomous University of Mexico), the foremost university in Mexico. Otherwise, the doctora explained, her life might have been similar to the women she attends. She is a striking contrast from Doctora Laura in her empathy; nevertheless, there are striking similarities in their approaches. She explains that Prospera wants as many women as possible to use contraception and notes with pride that her ability to speak the language gives her an advantage in achieving these ends. Other doctors rely on the asistentes to translate, she explains, but these “don’t translate it like it is.”
“Ay, no,” I tell them, “but it’s that [the asistente] is not saying what you are saying.” For example, family planning. “The doctora says,” he says, “but this is what the doctora said. No one, no one is forcing you. That if you want to.” Yes? “No one is forcing you. That if you want to. But if you don’t want to, there is no problem. Nothing will happen.” That’s not how they should translate. In some way, one has to pull a little the- um- how would I say it? The lasso, the reins, pues.
During a routine Pap smear, Doctora Mari was surprised to find that the woman, one of the few she had been giving the pill to for the past 5 months, had an IUD. Even more surprised was the woman herself, who gasped at the discovery. The woman explained that she had already had seven children when her last pregnancy ended in a miscarriage. She had become pregnant at the time despite having an IUD, which was expelled with the fetus. Crying and bleeding heavily, she was sent to the regional hospital. The woman wanted to be sterilized but her husband would not consent as he feared she had “another intention.” A common belief in the community is that sterilization makes women “hot” and they will no longer be satisfied by one man. Doctora Mari, noting this belief, offered to speak with the husband, but the woman feared he would get angry and scold her, and neither the woman nor her husband wanted another IUD which they blamed for her miscarriage. The doctora thus removed the IUD and assured the woman the problem had passed. The important thing, she stressed, was to keep taking the pill: “You have to take the pill, take the pill. Yes? Fine, then we’ll leave it at that, okay?” Afterward, Doctora Mari explained to me that someone at the hospital must have inserted an IUD without telling the woman. If a woman refuses birth control, she added, some doctors will insert an IUD during a Pap smear without her knowledge. The intention, the doctora explained, was only “that she won’t get pregnant anymore.”
Maternal mortality continues to be an important concern in this region (Rodríguez-Aguilar, 2018). The health care workers at the hospital, however, might have been equally motivated by fear of the consequences to themselves if this occurred. Citing a doctor who had recently been transferred following a case of maternal mortality, Doctora Laura in the municipal center explained, “This is why I always insist. This is why I oblige them. Almost, almost I oblige them. To avoid all of these problems, we have to watch over the population.” When I asked her about IMSS’s policy on family planning, Doctora Laura bluntly replied, “The policy on family planning? That they don’t have children, preferably,” adding with a sarcastic laugh, “Well, that’s how it is.” In her own way, she noted the contradiction between the health and human rights agenda that the program professed and the demographic goals that in practice it promoted. By providing financial assistance to pregnant women and women with children, Doctora Laura complained, the program incentivized fertility while pressuring health workers to promote contraception and reduce the fertility rate. She suggested that they adopt the “Chinese culture” instead, explaining with a dry laugh that they “fine the second child.”
Discussion
My aim in this article was to examine Indigenous women’s agency with respect to reproductive health care in the context of Mexico’s Prospera program. In line with the notion of a reproductive habitus (Smith-Oka, 2012), I have tried to illustrate how “modes of living the reproductive body” were instilled at the institutional and interpersonal levels (p. 2276). Importantly, many practices that I described were not inherent to the program. Rather, they revealed an interaction between the program and long-standing institutional habits and sociocultural factors that resulted in a reproductive habitus in which poor and Indigenous women appeared to be all but reduced to their fertility and reproductive risk. Practices such as the tight-knit hierarchy of supervision and the stress on quotas were eerily similar to the heavy-handed practices noted of IMSS in the past (Kirsch & Cedeño, 1999; Potter, 1999). Potter attributed the persistence of outmoded methods of contraception at least in part to inertia. If this is the case, then Prospera may be viewed as having added impetus to this inertia by providing new means and mechanisms of surveillance and control while greatly expanding the reach of the public health care system.
Organizational strategies such as the public display of women’s reproductive choices may reflect a broader problem of social assistance programs operating in regions where institutions are ill-equipped to process large numbers of beneficiaries; nevertheless, the failure to consider the basic privacy, comfort, and needs of beneficiaries reflected a lack of consideration of their bodily autonomy and rights. Ritualized activities such as assigning turns and waiting to be seen have been analyzed as symbolic expressions of social relations in institutional contexts (Ferrero, 2003, cited in Itandehui Saavedra et al., 2017). Studying a similar program in Colombia, Familias en Acción, Balen (2018) analyzed the striking queues, also a hallmark of Prospera, as a form of violence and public humiliation. Women were forced to stand for hours in the sun or rain, ignoring their physical comfort and needs and neglecting household duties including child care. Gastaldo (1997), applying the lens of biopolitics to public clinics in Brazil, argued that the use of fichas to assign turns, similar to the use I described here, transformed the national health system into an “experience of disciplining bodies” (p. 237); citizens needed be physically present to exist within the health care system, subjecting them to constant surveillance and control.
The public monitoring and grouping and shaming or praising women for their reproductive choices arguably took this disciplining a step further. In particular, the labeling of women according to their reproductive risk appeared to dominate and define their relationship with the health care system. Risk profiling has been analyzed as a form of social regulation. The label of “high risk,” implying a deviation from some norm, can be used to justify actions and interventions which under other circumstances would be considered invasive, abusive, or coercive (Lupton, 1999; Petersen & Lupton, 1996). These tendencies were arguably compounded for Indigenous women who are already considered deviant (cf. Smith-Oka, 2012) and by the structure of Prospera. Stereotyped as hyperfertile and lacking self-control, the women were mocked and scolded, threatened and violated all within a discourse of being “for their own good.” Such practices, however, appear to be pervasive in Mexico’s public health sector. Erviti et al. (2010), in interviews with male doctors in central Mexico, found some felt justified, even that it was their professional obligation, to “almost force” women to accept an IUD or sterilization due to “institutional pressure, the dangers of overpopulation, and reproductive risks” (p. 781). Moreover, they viewed patients’ right to refuse a contraceptive method as a potential risk to themselves, echoing the attitudes of doctors that I described here. Poor women more generally are therefore viewed as a risk to themselves, to their children, to health care workers, and ultimately to the nation.
The outstocks of short-acting contraceptive methods is a poignant example of how the institutional and interpersonal levels worked together to enact and justify abusive practices. Dansereau et al. (2017), in focus groups in some of Chiapas’ poorest municipalities, including five Indigenous communities, found that participants described similar outstocks of hormonal methods and held misconceptions about their side effects, with some citing health care workers as their source of information. Torres-Pereda et al. (2019), in interviews with mestizo participants in six Mexican states, found evidence of an “inverse availability,” a shortage of preferred methods coupled with the availability of the least preferred methods. Participants reported that pressure to choose the IUD was particularly intense during post obstetric events and especially in urban clinics, sometimes resulting in its forceful insertion. Such outstocks therefore, although they may have been intensified in Indigenous communities and within Prospera, are not limited to these contexts. Nor are they new: A 1996 UN Population Fund analysis of service providers in Mexico (described in J. L. Jacobson, 2000) found that a limited number of contraceptive methods were offered, and providers were required to strongly encourage and persuade women with two or more children to adopt the IUD or sterilization. Perhaps one reason for the persistence of such outstocks is that they give the illusion of consent and that clinics are meeting women’s contraceptive needs, like the woman who came asking for the injection and left agreeing to an IUD. But as J. L. Jacobson (2000) notes, A programme that offers limited methods in the interest of reducing women’s fertility, takes advantage of their already limited sense of entitlement in order to achieve externally posed goals, and fails in any way to instill a sense of broader choices and entitlement, does not meet the test of contributing to the promotion of reproductive rights. (p. 24)
Finally, the second case of the hidden IUD illustrates what can happen when conflicting interests seek to control women’s fertility. Although I cannot speak to the extent of such practices, this example provides insight into the complex network of institutions and inequalities, practices and beliefs that created a reproductive habitus in which serious violations of women’s bodily autonomy and human rights were not only enacted but also believed to be justified.
Conclusion
The practices that I have presented are clearly problematic from a health and human rights perspective, but they also raise questions about the ability of conditional cash transfer programs to meet their long-term goal of eliminating poverty through effecting lasting behavioral change. Twenty-two years after the start of Prospera, the goal of eliminating poverty has remained elusive (but see Kugler & Rojas, 2018 for evidence of long-term positive effects on employment outcomes). The program has yielded many positive results, including arguably helping to reduce the maternal mortality rate which is negatively associated with contraceptive use (Rodríguez-Aguilar, 2018). Nevertheless, Mexico continues to lag behind its Millennium Development Goals in this respect, with rural and Indigenous women disproportionately affected (CEDAW, 2018; Rodríguez-Aguilar, 2018). Perhaps ironically, there continues to be an unmet need for contraception in Mexico despite the practices I described (Juarez, Gayet, & Mejia-Pailles, 2018). What will happen to women’s reproductive health now that the program has ended? As noted, studies have shown a link between women’s empowerment and contraceptive use. Numerous studies have also found that when patients feel that they have been treated with dignity, they are more likely to report better adherence to treatment and greater satisfaction with health care services (see J. L. Jacobson, 2009 for a review). To achieve the goals of reducing rates of maternal mortality, increasing the use of reproductive health care services, and improving child welfare, it would therefore appear to be in the interest of Mexico’s health care institution to redress the abusive practices described here.
Notably, such practices are difficult to document, and therefore difficult to change. They are not written in official policies and some women I spoke with reported feeling uncomfortable speaking out or filing complaints—either for fear of being dropped from the program and/or because they lacked the social capital to do so, including Spanish language and literacy skills. Whatever the ultimate fate of Prospera and the many CCTs it has engendered, a concerted effort is needed to change the reproductive habitus in which abusive practices have been normalized while addressing barriers to the use of reproductive health care services. Suggestions include addressing the barriers to access to a wider array of contraceptive choices. This includes providing better training for health care workers to provide more accurate information about the benefits and risks of different methods so that women can make informed choices. Training is also needed in implementing internationally accepted procedures for informed consent and maintaining the privacy of individual health information. Health care institutions need to de-emphasize quotas and reduce the pressures on medical personnel while providing training and resources to promote a better quality of care. The ficha system could be replaced with a method of scheduling appointments that respects the time, comfort, and privacy of patients. Recruiting more health care workers who speak an Indigenous language is important, as recognized by IMSS (IMSS-Prospera, 2017), but does not eliminate the need for cultural sensitivity and cultural competence training. There were, of course, limitations to this study. Each clinic was largely shaped by the doctor who ran it, potentially limiting the generalizability of these findings. Nevertheless, the patterns that I report held across highly contrasting health care workers, concord with other studies, and fit the history of abusive practices in the region. It is also worth emphasizing that all health workers and practices were not abusive. Most health care workers were dedicated, hardworking, and arguably doing the best they could under challenging circumstances. Many were also cognizant of the pressures and abuses within IMSS, giving hope that future reforms can indeed yield change.
Footnotes
Acknowledgements
Thanks to Donna Castañeda, Esperanza Camargo, and Rubén Muñoz for their feedback on an earlier draft, and three anonymous reviewers for their helpful comments and suggestions. Thanks to Antonieta López Santiz and Juan Méndez Girón for their work on transcriptions and translations. Thanks also to CIESAS-Sureste, especially Graciela Freyermuth and members of the medical anthropology research group. I especially wish to thank the community members, health workers, and health institutions, without whose cooperation this study would not have been possible.
Declaration of Conflicting Interests
The author declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by an individual research grant from the Ruth Landes Memorial Research Fund of the Reed Foundation. Follow-up trips were funded by San Diego State University including a University Grants Program grant from the SDSU Research Foundation.
