Reproducing Inequality: An Examination of Physician Decision-Making During Childbirth in Merida, Mexico

摘要

Anthropologists have long recognized that health is directly shaped by political, institutional, and sociocultural context. This variability is especially apparent in examining medical-decision making within particular systems of health care; for example, who can make decisions and the type of decisions that may be made differs notably between settings. Childbirth is a salient window through which to explore the impact of broader social, cultural, and economic factors on decision-making, as the location of birth, interventions, and use of technology profoundly differ based on setting. Childbirth delivery method is a striking example through which to consider the impact of context on physician decision-making, as rates of Cesarean sections (C-sections) significantly vary worldwide. Mexico is an especially appropriate location to examine the decision for a C-section, as Mexico maintains the fourth highest C-section rate in the world. C-section rates have historically been the highest in the setting of the private hospital, as factors such as patient demand, financial motivation, and increased convenience have resulted in a C-section rate around 70%. C-section rates in Mexico are also increasing in the public hospital sector, where approximately 38% of deliveries are performed via C-section. It is unclear why C-section rates are surging in the setting of the public hospital, given that physicians are paid a set salary regardless of delivery method and work pre-determined shifts.;This dissertation presents the findings of a research project performed in 2014- 2016, exploring physicians' decision-making process for delivery method at two public hospitals in Southern Mexico. Utilizing participant observation and semi-structured interviews with 24 physicians at two public hospitals in Merida, Mexico, this dissertation examines how physicians' understanding of institutional demands, medical hierarchy, and the patient population influences their decision for a C-section. Based on these findings, it is argued that physicians' various positions within the medical institution, along with Mexico's complex history class and race based discrimination, distinctly shape physicians' perspectives on patient management. While physicians working in hospital administration emphasize the importance of meeting the state and federal government's benchmarks for maternal health, senior and resident physicians are primarily concerned with ensuring a "safe" delivery within the constraints of the public hospital. Senior physicians focus on potential legal repercussions for an adverse outcome, while residents attempt to reconcile their medical knowledge with the strict hierarchy of these hospitals. I argue that an unintentional effect of the intense focus on outcome within the Mexican health care system is that as physicians in these hospitals struggle to avoid poor outcomes while facing limited resources and a heavy workload, they come to view technology like C-sections a crucial strategy for achieving a safe birth. Ultimately, I posit that Mexico's system of stratified health care has resulted in magnifying existing social, cultural, and economic disparities, as patients' needs are relegated as secondary to bureaucratic demands.