by Sarah Smith

Women embrace obstetric technology—often migrating transnationally to seek what they perceive as safer birthing options—only to face the social stratification inherently embedded in biomedicine, putting their bodies at risk. I explore Chuukese women’s desires to migrate to Guam for higher-tech births, despite suffering disproportionately poor birth outcomes upon arrival. I ask: what is it about obstetric technology that gives people so much faith, even in the face of stratified reproduction?

Where is the best place to give birth? Feminist anthropologists have examined this question, in all its iterations, for decades. We have explored the birth experiences of women across the world, questioned the biomedical control of women’s bodies, and critiqued development initiatives that deny credibility to traditional midwives. While we spend time critiquing the reach of biomedicine, many increasingly mobile women throughout the world leave their own perceived “unsafe” spaces for “safe” biomedical births. However, upon traveling to “modern” facilities in wealthier city-centers or nations, women face the institutional racism, classism, sexism and poverty ingrained in biomedical environments, putting their birthing bodies at risk. I spent two years conducting an ethnographic study of Chuukese women’s reproductive health in Guam, including women birthing in Guam despite facing these risks, and wrote about this phenomenon in Medical Anthropology.

Guam is an unincorporated territory of the US, and Chuuk is one state of the Federated States of Micronesia (FSM), a country in a unique relationship with the US, formed after decades of these islands being designated post-WWII “trust territories.” This relationship allows FSM citizens the ability to freely travel, live and work in the US without a visa. Since this relationship was codified in 1986, FSM citizens began moving into the US for better education, jobs and access to health care; particularly for those from Chuuk’s 23 inhabited islands, migration often starts with nearby Guam. As this began, anti-immigrant resentment and discrimination toward Chuukese migrants grew in Guam, and rhetoric about the Chuukese arriving only to give birth for citizenship, food stamps and welfare is widespread. Yet, women continue to seek what they see as safer births in Guam.

Childbirth in Chuuk

This was not the first shift in Chuukese women’s birthing choices over the last century. Older anthropological accounts portrayed birth as a reason for women to go home to their familial land, where they would be cared for by an expert midwife and older female kin who were the primary support system. This first changed when a hospital was built in the main island in the mid-20th century; women were encouraged by newer colonizers to birth in this shiny new biomedical space. At this point, many women who could afford the boat ride left their home islands and midwives and headed to the hospital. Ingrained in this new mentality was that biomedical professionals were necessary, “just in case” something bad happened; more technology meant better outcomes. Anthropologist Melissa Cheyney calls this phenomenon the “obstetric imaginary,” an unyielding belief and trust in the biomedical establishment to improve lives and to reduce suffering in all circumstances. Biomedicine often contributes to saving lives and reducing suffering, but we also know that a) sometimes it does the opposite, for a variety of reasons; and b) care is highly stratified, often reflecting community inequalities.

In Chuuk, development funding is not sufficient to support the high expenses of biomedicine, and the hospital declined dramatically over the years. Chuuk’s hospital grew to be a place known for a shortage of staff and supplies in a deteriorating building with holes and leaks throughout. Locals call it “the place to die.” As a result of this decline and loss of trust in Chuuk’s biomedicine, women didn’t return home to trusted midwives; they went transnational. They started to leave Chuuk for safer birthing spaces with more technology, beginning with Guam.

This ethnographic study included life history interviews with 15 Chuukese women, semi-structured interviews with 24 health care workers providing reproductive health care, and the shadowing of over 100 women seeking care in Guam’s reproductive health clinics. Of the women I shadowed in Guam, the majority were there for prenatal care. While these women were often residents, many were also visiting Guam for birth. These women wanted to live in Chuuk, but did not feel safe birthing there. When I asked women why they chose to leave, they said things like “a lot of babies die in Chuuk, and a lot of mothers.” Others described a bad experience with a previous birth, and some complained of giving birth with no attendants, a symptom of a very underfunded and understaffed system. So, those pregnant women with families who could afford the airfare traveled to Guam to give birth.

Is Guam better? Safer?

Women regularly told me Guam was a much safer option. Nelly told me, for example: “It’s a really big difference. Health care here [Guam], it’s really, very good. It’s not, there’s nothing I can compare to the one in Chuuk.” Yet, I wanted to conduct this research because Chuukese women suffer the worst reproductive health outcomes on the whole island of Guam. They have more C-sections and higher rates of complications, including maternal and infant mortality. Of course, Guam Memorial Hospital (GMH) is suffering from its own neo-colonial existence as well—with scarce funding, limited skilled personnel and a large indigent population—the hospital has a reputation for inadequate care. Its financial woes are inevitably blamed on the migrants seeking care without insurance, and these feelings are transferred to Chuukese patients birthing in Guam, further stratifying their reproduction.

Stratified reproduction is an anthropological concept which delineates how stratification in society is shaped and maintained by reproduction. Chuukese women’s reproduction was stratified through local policies meant to slow the flow of federally sanctioned migrants, and through treatment by hospital personnel. First, to qualify for Guam’s Medically Indigent Health Insurance Program for non-U.S. citizens, applicants had to be Guam residents for six months. This meant women who arrived just a few months before birth did not have time to get insurance. Without insurance, women could only register at GMH if they had a large (about $200) down payment. Because of this, many lower-income women waited until they were in labor to arrive at the emergency room, often with no records, thus bypassing the required fee.

Women also experienced resentment and discrimination from health care workers. Women told me again of giving birth without attendants; some were given C-sections without understanding what was happening; others were sent home despite high blood sugar or blood pressure—complications that led to poor and sometimes lethal outcomes for them and their babies. Women felt hospital providers treated them worse because they were Chuukese. They told stories of providers lecturing women—while in labor—that they should stop having so many babies.

Health care providers had their complaints as well. They complained about Chuukese women’s silence in labor, because they could not assess how far along these women were in the birth process. They also complained that Chuukese women reached the hospital too late. Conversely, several Chuukese women I spoke with proudly told me that by the third or fourth child, they could time it just right: arriving as they were pushing the baby out. This demonstrated their strength in the birthing process, allowing them to avoid a discriminatory atmosphere until they absolutely had to be there. Because—while Guam was perceived as much better than Chuuk—it was not ideal for a Chuukese woman. Women who could afford to get further to Hawai’I or to the west coast—left Guam for what they saw as more technology and thus “better” biomedicine. Yet, for those who could only afford to get to Guam, they believed it was much better than their home island or Chuuk State Hospital. Care was stratified by the cost of a boat ride or plane ticket.

As with the rest of the world, the cultural power of almighty biomedicine has made its way to Chuuk and Guam. Communities still appreciate and respect local medicine, and often integrate methods from both medical traditions for pregnant women, but for childbirth, people have embraced the obstetric imaginary. Chuukese women and their families trust that obstetric medicine is the safest option and yet, it continues to fail them. In spite of their best efforts to circumvent the low-technology options in Chuuk and their deleterious effects through pursuing the “best” care transnationally, Chuukese women migrate only to confront the worst birth outcomes in Guam. What is unique is not the pervasive power of global biomedicine, or the obstetric imaginary. This trust in obstetric technology is pervasive throughout the world. The unique element here is that obstetric medicine continues to invoke a sense of trust in saving lives in the context of stratified reproduction. This imaginary is so powerful that it persists even as biomedicine’s unequal distribution of care endangers women’s lives.

Sarah A. Smith is Assistant Professor of Public Health and Co-Director of the Health Disparities Institute at SUNY Old Westbury. Her research examines sexual and reproductive health at the intersection of US colonial policy, gender, and migration in Micronesian communities. Her research has been published in Social Science and Medicine and Medical Anthropology.