Candace Johnson

Political science professor Candace Johnson will be very busy as of January 2013. She’s bringing her family with her to Guatemala, where she’ll be coordinating the semester abroad program, teaching two courses, and, “since I was going to be there,” adding research on maternal health preferences among Guatemalan women to her study that previously covered four countries.

She’s completed her research in Canada, Cuba and Honduras and will be working soon at one of two possible U.S. sites. Adding Guatemala will provide yet another perspective, she hopes.

Johnson’s work examines the different perspectives women have about care during pregnancy and birth. Both of her children were born in hospital, but she says she’s noticed that other Canadian women made different choices. “There seems to be a trend towards the use of midwives and home births, what we might call non-medical options for pregnancy and birth.”

At the same time, in developing countries, efforts are being made to increase the percentage of women seeing doctors during their pregnancies and giving birth in hospitals to reduce maternal mortality. The World Health Organization recommends having a skilled birth attendant – a trained midwife, nurse or doctor – for every woman, and in many places that means giving birth in a hospital or clinic. “I wondered why we seemed to be going the opposite way in Canada, and what the political dynamics were behind this,” she says.

In Honduras, for example, where Johnson has been working with U of G graduate Elaine Hernandez, she says that great efforts are being made to encourage more institutional births. “Despite many incentives, a large number of women still opt not to go to the clinic or hospital,” she says. Johnson interviewed women in the more isolated communities, and found that unlike Canadian women, they weren’t eager to talk about their preferences or experiences.

“They know that they are being encouraged to go to the birthing clinic,” she says. “Some said they wanted to, but couldn’t get there in time because of a lack of transportation. It was what was practical for them at the moment.” Many talked about the need for more support from their husbands, something the Red Cross in Honduras has been trying to address.

Johnson said she was surprised by the number of women who described giving birth at home alone, as well as those who said they couldn’t go to the clinic because they had no one to care for their other children. “Why, in a community where everyone lives close by, would you give birth alone?” she wonders. “Why, when you had lots of relatives living nearby, was it impossible to find someone to watch your children when you went to the clinic?” It’s possible, she adds, since the questions were being asked by Red Cross workers, that the women knew the answers that were expected (that they wanted to go to the clinic) so gave what seemed like plausible excuses.

Another woman commented about going to the clinic: “We have to be compliant.” Johnson adds: “Is that what we want – women being compliant? Is that a good thing or a bad thing? In Canada we’d think of this as a bad thing, but if it reduces maternal deaths and allows more children to thrive, maybe it’s a good thing.”

In Cuba, government policy requires all women to give birth in hospital with a doctor; they are even followed up if they miss a prenatal appointment. The women Johnson interviewed are very happy with that and said they couldn’t understand why anyone would choose a home birth. “They see it as going back in time, and they are proud of their progress,” she says.

Cuba has better infant mortality rates than the U.S., and much better rates than neighbouring countries such as Honduras. “The women do have complaints,” adds Johnson. “They wish that pain medication was available for normal births – it’s currently only used for Caesarean sections. And they would like to have continuity of care, where they’d see one doctor through pregnancy and the birth.”

The Cuban women also feel hospital care has deteriorated in the past 20 years: patients now have to bring their own buckets and a water heater if they want hot water, for example.

Johnson’s interviews in Canada sought to compare Canadian-born and immigrant women. “I found that the overwhelming preference was for care by an obstetrician or doctor and birth in the hospital,” she says. “However, many of the Canadian women said they liked the idea of care from a midwife or family doctor even if they went to an obstetrician.”

The Canadian women who went to midwives said they preferred a woman-centred approach and wanted more control and autonomy. “A lot of them talked about rejecting or resisting technology,” says Johnson. “They did not often mention their husbands or family – it was more about their experience.”

Few of the immigrant women, she found, opted for midwives. “When they did, it was usually because they saw the midwives as substitute family, since they were separated from their own families,” Johnson says.

She’s looking forward to discovering what additional insights she can gain when she interviews mothers from the U.S. (she’s considering either Washington, D.C., or Texas as possible sites) and those in Guatemala. “I expect to have this all written up by the end of 2013,” she says.