Saving face, losing life: obeah pregnancy and reproductive impropriety in Southern Belize

Abstract

References to obeah pregnancy are widespread in southern Belize, where the belief in supernatural forces combines with Catholic teaching to create a conservative reproductive climate in which illegitimate pregnancy, reproductive misfortunes and maternal death are located in a discourse of shame. Obeah pregnancy is said to result when spiritual forces are unleashed through malicious human intent, causing bodily changes that resemble pregnancy. Death of the woman, however, usually occurs before prenatal confirmation; thus it is often unclear if an obeah pregnancy is a viable pregnancy or some other biomedical – or metaphysical – condition. This paper provides a case study of Petrona, whose story is unique in that she does not die from her purported obeah pregnancy; rather, she lives to bear the consequences of her reproductive behaviours that resulted in the stillbirth of a full-term foetus. Petrona was a traditional birth attendant who is trained to uphold biomedical antenatal protocols. Arguing that Petrona was not adequately educated to fulfill her own prenatal obligations, health care personnel sanctioned Petrona's midwifery practice and left her to process her ‘shameful’ situation. Ultimately, Petrona's story complicates the culturally disengaged narratives of maternal health and highlights the schism between medical knowledge and socioculturally influenced embodied experience.

Les références à la grossesse obeah sont très répandues dans le sud du Belize, où les croyances en des forces surnaturelles sont associées à l'éducation catholique pour créer, autour de la reproduction, un climat conservateur qui situe la grossesse illégitime, les incidents liés à la reproduction et la mort maternelle dans un discours de honte. Il est dit de la grossesse obeah qu'elle se produit quand des forces spirituelles se déchaînent à travers des intentions humaines malveillantes, provoquant des modifications corporelles semblables à celles de la grossesse. Cependant la mort de la femme se produisant habituellement avant la confirmation de la grossesse, il est souvent difficile de dire clairement si une grossesse obeah est viable, ou si elle n'est pas plutôt la manifestation d'un autre problème biomédical – ou méthaphysique. Cet article expose le cas de Petrona, dont l'histoire est unique en ce sens qu'elle ne meurt pas de sa grossesse, pourtant considérée comme obeah; au contraire, elle vit pour endurer les conséquences de ses comportements reproductifs ayant abouti à la mortinaissance d'un bébé arrivé à son terme. Petrona était une sage-femme traditionnelle ayant reçu une formation pour intégrer les protocoles prénatals biomédicaux à sa pratique. En partant du principe qu'elle n'était pas suffisamment éduquée pour remplir ses propres obligations prénatales, le personnel de santé a sanctionné sa pratique de sage-femme et l'a laissé gérer toute seule sa situation «honteuse». Au bout du compte, l'histoire de Petrona complique les récits désengagés sur la santé maternelle et souligne le schisme entre les connaissances médicales et l'expérience incarnée, et influencée par le contexte socio-culturel.

Las referencias a los embarazos por el ritual obeah son muy comunes en el sur de Belice, donde la creencia en las fuerzas supernaturales se combina con la enseñanza católica para crear un clima reproductivo conservador en el que los embarazos ilegítimos, las desgracias relacionadas con la reproducción y la mortalidad materna son temas incluidos en un discurso de vergüenza. Según la brujería africana obeah, los embarazos ocurren cuando fuerzas espirituales se desarrollan a través de intentos humanos maliciosos causando cambios corporales que se parecen al embarazo. Sin embargo, la mujer generalmente se muere antes de la confirmación prenatal; por eso no está claro si un embarazo mediante el ritual obeah es un embarazo real o algún otro estado biomédico, o metafísico. En este artículo ofrecemos el caso práctico de Petrona, cuya historia es única porque no muere del supuesto embarazo obeah sino que vive para asumir las consecuencias de su comportamiento reproductivo que tuvo como resultado el parto de un feto muerto a término. Petrona era una partera tradicional capacitada para mantener los protocolos prenatales biomédicos. Con el argumento de que Petrona no estaba adecuadamente formada para cumplir sus propias obligaciones prenatales, el personal sanitario sancionó la práctica partera de Petrona y dejó que tratara con su propia situación ‘vergonzosa’. En última instancia, la historia de Petrona complica las narrativas culturalmente desconectadas de la salud maternal y pone de relieve el cisma entre el conocimiento médico y la experiencia personificada influida por factores socioculturales.

Keywords:

• pregnancy
• Belize
• midwifery
• shame
• obeah

Introduction

‘You no know what is obeah pregnancy?’ My eyes widened. This was the first time I had heard an indigenous Maya use the word obeah to describe a type of magical practice that is commonly referred to in the African diasporic communities of the Caribbean. Petrona's1 voice quieted as she continued:

For nine months, a lady's belly get big, big. But there is no baby. Her belly get big because the man go to the bush doctor for obeah the lady. Maybe he vexed because she no want to have sex with him, so the man make the bush doctor obeah she. Then blood come from between her legs and she dead.

Moving to the edge of my seat to hear more about this frightening phenomenon, our conversation was cut short when Petrona, a 39-year-old Maya woman from a distant village, realised that she had only a few minutes to catch the return bus to San Tómas – a three hour journey on a rickety US-brand school bus into the heart of the Maya Mountains. We agreed to continue our conversation in two days when she would return to town.

Our second conversation, however, never occurred. Unbeknownst to me, Petrona was nine months pregnant. On the day after our discussion about obeah pregnancy, she was rushed to the hospital, haemorrhaging with placenta previa,2 where she underwent an emergency Caesarean section. When Petrona went into labour, the low-lying placenta detached, causing massive uterine bleeding and foetal demise. Upon admission to the hospital, Petrona herself was on the brink of death.

While this story is harrowing, the risks Petrona took to conceal her pregnancy, the rationale with which she justified her actions and the shame she experienced around her condition are not anomalous. What makes this case exceptional is that Petrona was also a midwife and, despite her biomedical training, the removal of a dead foetus from her womb and the admission of having engaged in what is culturally regarded as shameful premarital sexual activity, Petrona continued to believe in the supernatural power of obeah to explain her problematic reproductive status and remedy the social stigma surrounding her condition.

In this paper, based on ethnographic fieldwork with midwives working under the Ministry of Health (MOH) in the Toledo District of southern Belize in 2006, I argue that obeah, dominantly portrayed as a counter-hegemonic force, can be agentively commanded by women to uphold normative representations of female sexuality and reproduction. Petrona's use of a discourse of shame to convey a particular message about her reproductive dilemma illustrates the rigidly defined ideal gender expectations that complicate the culturally disengaged development narratives of maternal health. Thus, I argue that in southern Belize, where women's reproductive behaviour is highly scrutinised, obeah and shame are cultural tropes that influence women's health and reproductive decisions – and may cost some their lives.

Pregnancy and childbirth in a rural village

The population of the Toledo District is a multi-ethnic mixture dominated by two linguistically distinct Maya groups (Mopan and Kekchi) and the Garifuna, a population defined as a mixture of African and indigenous Carib and Arawak. Although numerous languages, which correspond to the ethnicity of the speaker, can be heard throughout the region, the English-based Belizean Creole quoted throughout this article is a common linguistic thread. As a former British colony, the culture of Belize is marked by its association with the Queen and the Anglophone Caribbean.

In Toledo's rural villages, most women birth at home with the assistance of close kin. Hospital accessibility is adversely affected by bad weather conditions and lack of transportation. But potentially more prohibiting are the culturally prescribed gendered expectations about proper reproductive behaviour, including women's expressed shame about exposing their genitals to a non-family member during birth. Village women usually give birth in a kneeling position and fully covered by their long skirts; the presence of outsiders is not welcomed.

In the absence of a trained biomedical care provider, perinatal complications are handled by ‘bush doctors’ who provide spiritually-based treatments including hile'ek, a form of uterine massage that is known to remedy pain, stalled labour or foetal malpresentation. At times, a bush doctor may determine that labour is not progressing because the woman has been ‘obeahed’, for which the bush doctor can perform additional spiritual healing practices to counter the negative spell and enable a successful delivery.

Indeed, bush doctors are specialists in obeah, a type of magical practice that uses supernatural powers to alter the physical world. Obeah has been written about extensively in the African diasporic communities in the Caribbean region, but it has never been identified as such among the indigenous Maya populations of Central America. Historically and conventionally, obeah (and its practitioners) has been associated with counter-hegemonic activities like slave rebellions, while concomitantly typified as a superstitious cultural practice that is inferior to scientific European rationality (Richardson 1997; Earle 2005). However, in southern Belize, a number of bush doctors who provide spiritually-based services have been incorporated into the world of rational biomedical care by the MOH's public health outreach campaigns (MOH 1987, 21). In Petrona's village of predominantly Mopan-speaking Maya, the bush doctor was integrated into the Belizean public healthcare system as a Community Nurse's Aide (CNA), in line with the tenets of ‘participatory health care’ (WHO 1978) and related to the certification of community-based ‘traditional birth attendants’ (TBAs) (Oakley and Houd 1990, 175) – the training of which was begun by the Belizean MOH in 1952 (Sibley 1993, 43) and continues to the present. Due to limited economic and human resources, the method of instruction is highly individualised and practical (Sibley 1993, 46) and the numbers of TBAs trained by the Belizean Ministry have always been small. As such, many of the rural areas in Toledo remained without a trained midwife. In 2000, Gift (Giving Ideas for Tomorrow), a US-based NGO, initiated a TBA training programme to address this shortfall. Petrona was among Gift's initial group of trainees.

When I first met Petrona, nearly six years after her training, she had attended very few births. Although pregnant women in her village would come to her for hile'ek – a service for which she was not trained to provide, but that she could imitate through the prenatal palpation techniques she learned to assess fetal development – women continued to deliver their babies at home with family members. Petrona attributed this to a combination of factors including a shame affect that precluded non-kin from attending a birth. More important, however, was – she believed – the negative influence of the CNA, whose purported antagonism against Petrona had been fomenting for several years.

Immaculate conception

Throughout my research, Petrona and I enjoyed a very close friendship and our conversations became quite personal. We often discussed our views about the world –and our love lives. As a professed Catholic, Petrona firmly believed that she should marry before having children. ‘But,’ she lamented, ‘there are no men!’ With nearly even distribution of the sexes in Belize's population (Central Statistical Office 2006), Petrona clarified her overstatement. Indeed, she had been proposed to on two occasions when she was in her mid-teens, but Petrona had declined the offers. As she approached the age of 40, Petrona regretted not having accepted one of these earlier marriage proposals. She had resigned to accepting life with no foreseeable prospect of a husband or children. But what about sex?

Many of the early ethnographies of the Caribbean region took kinship and family organization as the basis for the analysis of social life (Henriques 1953; Smith, R. 1956, 1973; Smith, M. 1962). Although they found high rates of extended female-headed households, multiple partnering relationships and illegitimate births, the dominant construct of female sexuality throughout the region remains influenced by a Victorian value system characterised by monogamous conjugal union and legitimate offspring (Mohammed and Perkins 1991; Barrow 1996). Belize, historically connected to Caribbean economies of power, is similarly dominated by these ideals (McClaurin 1996, 114; Kerns 1997 [1983], 114), which are reified through the religious influence over the education and legal systems. The Catholic Church finances the majority of public schools, the curriculum of which includes religious instruction and church attendance. In Toledo, high school girls who become pregnant are automatically and indefinitely expelled, while boys go unpunished. Government institutions cannot dispense birth control and abortion is illegal.3 A religiously influenced discourse of shame keeps many women from openly discussing their sexual activities. However, when they become pregnant, there is little they can do to avoid the public scrutiny of unwed motherhood (Edgell 1982).

Four weeks after her Caesarean section, Petrona had her stitches removed at the town hospital, and we met for the first time since our portentous conversation about obeah pregnancy. I was feeling admittedly awkward about the situation. As an anthropologist studying reproduction, I was professionally interested in asking her all kinds of socially inappropriate questions. However, as an ethical researcher – and a friend – I knew to lend a sympathetic ear and wait for her to offer the details of an undoubtedly traumatic event.

Petrona did not say much while we ate pastries and drank lime juice. When I finally asked about her pregnancy-related hospitalisation, she denied all knowledge of the pregnancy, stated that she did not know how it happened and adamantly claimed never to have had sex. When the time came for her to catch her bus back to San Tómas, Petrona's stop in a public bathroom ended with a cry for help. Standing near the toilet, Petrona raised her skirt and nervously asked me what I saw. Fresh blood was seeping from the bandages covering her Caesarean incision. I quickly found a taxi to bring Petrona back to the hospital.

Four weeks later, Petrona was discharged and came directly to my house to recuperate – and process her shame. Petrona was understandably quite afraid of what her mother would do to her when she learned about the pregnancy and village gossip had mounted. But she was not anticipating the backlash from the MOH supervisory personnel who were openly discussing what should be done about a village midwife who did not follow prenatal protocols, endangered her own life, and brought about the death of an unborn child.

The socialisation of shame

Margaret Mead and Ruth Benedict first popularised ideas about shame- and guilt-based cultures in their explanations of the relativistic means by which societies enforce social organisation and hierarchies (Mead 1937; Benedict 1946). According to Benedict (1946), ‘shame-based’ cultures are centered on conformity to unwritten rules and the maintenance of honour and appearance. They precede the evolution of ‘guilt-based’ cultures, which are based on juridical rules, internalised conscience and notions of punishment. More recently, however, Giddens (1991) has argued that shame is prevalent in the modern world, even surpassing guilt as a self-motivational regulatory feature that governs social interactions (69).

Indeed, in modern contemporary populations – like those found in Toledo – ‘hame, whether internally or externally experienced [through conscience or through violation of juridical law], is one of the supreme means of ensuring social order, social control and individual conformity’ (Pattison 2000, 135). During my fieldwork, I heard frequent reference to shame that reflected this dual nature of the socialisation process, which began with young children and remained prevalent throughout adulthood. At school, children are socialised to act according to normative standards of physical appearance through a uniform dress code and to accept authority by reciting instruction with little analytic explanation or diagnostic tools. Deviation from socially acceptable conduct is met (in and out of the classroom) with public censure and shame through verbal reprimand (being ‘scolded’ or ‘cussed out’) and physical punishment (being ‘lashed’, usually with the hand, a shoe, a belt or a stick3). Corporal punishment of a child under the age of 16 is lawful under the Belizean Criminal Code and Belizeans in Toledo are quick to cite the Bible to explain how lashing teaches humility before God – and, by extension, respect for the local social order.

Both verbal and physical punishment is often conducted in plain view of the community to elicit the regulating shame affect. At a group meeting I attended for young women, a Garifuna teenager explained that even though it was physically painful, she preferred being lashed to being cussed out, because the lashings were done quietly. Sharonda, aged 16, explained, ‘When me ma lash me, no one could hear. But one time, me ma mi catch me with a boy. And she mi rail-up [scold me]. The whole lane mi hear. Now I 'shame for that’. Despite Sharonda's private lashings, I witnessed many public lashings of children conducted in front of peers – especially in the school yard by parents or in the classroom by teachers – to purposefully invite the gaze of others, thereby bringing the awareness of an individual's deviant behaviour to the public attention and eliciting the coercive force of public shame.

Shame is also an internal affect such that to feel shame, ‘we do not need the pressure of an actual shamer or even a viewing audience; we need only these internalised figures that have become part of who we are’ (Morrison 1996, 16). Liza, an unmarried Garifuna woman now aged 32, was living in town when she became pregnant with her second child at the age of 23. Liza recalled:

I mi already eight months pregnant before I join clinic, and only after Nurse Lee scold me in the street. I think I no want to join clinic ‘cause I no want people to know I mi pregnant. My first baby was not even two months old and I pregnant again! But Nurse Lee, she scold me for no join clinic and for why I have the next baby so quick. Nurse Lee, huh! She like for do that. When she hear that someone is pregnant and no join clinic yet, she will go to their house and scold them, and bring them to join right now!

Liza's story describes the shame she felt because of her socially inappropriate reproductive state. Both of her pregnancies indexed her sexual behaviour, but the second one, within months of the first, suggested that her sexuality was uncontrollable, and Liza did not want her pregnancy – or her sexuality – to be publicly acknowledged. However, her behaviour was eventually discovered by Nurse Lee, a Garifuna woman in her 50s who was the local public health nurse and the director of the maternal and child health programme. Nurse Lee shamefully reminded Liza of her reproductive responsibilities by publicly ‘scolding’ her in the street for not attending the prenatal clinic and for becoming pregnant so soon after the last pregnancy – in disregard for the MOH's endorsement of the international maternal health strategy of two-year child spacing. Although Nurse Lee did not reprimand Liza for being an unwed mother, Nurse Lee's attention to the successive pregnancies reinforced Liza's internal shame regarding her sexual activity. Given her unmarried status, Liza's second pregnancy was doubly shameful.

While, ‘I 'shame’ (I am ashamed) was frequently uttered by both men and women whose socially deviant activities came under the public gaze, references to shame stemming from sexual and reproductive behaviours were uniquely made by women. Women use a language of shame to describe their perceived personal failure (Freud 1961[1930]) when they deviate from the unequally gendered social – and religious – expectations for women, who should remain chaste until marriage. According to the census data current at the time of my fieldwork, 38% of the births in Toledo were to unmarried women (country-wide the figure is much higher at 59%) (Central Statistical Office 2006).4 These figures suggest that there is a gap between actual practices and the social ideal. Women in Toledo are engaged in sexual activity before marriage, but for women like Sharonda and Liza, premarital sexual activity is met with shameful reprimand. Because she was pregnant, Liza's body was subjected to increased surveillance through public health measures and local forms of control like those exhibited by Nurse Lee who, according to Liza, will seek out pregnant women in their own homes and scold them if they have not yet publicly acknowledged their pregnancies at the prenatal clinic. Unwed pregnancy remains a shameful condition that obstructs the preventative maternal and child health care measures of the MOH and creates additional forms of perinatal risk for the women who, like Liza and Petrona, try to conceal their pregnancies from public view.

Shameful reproduction

One day, while Petrona was staying with me, I came home to find her standing transfixed in front of the TV. With her head tilted to one side and her hands clasped in front of her abdomen, Petrona's gaze was set upon a televised image of a Catholic mass depicting a statue of a bleeding Jesus. I was afraid to interrupt her thoughts, but I began to feel like a voyeur in need of announcing my presence. I timidly asked Petrona if she was feeling okay, and her response broke the trance, ‘I am a sinner. I 'shame’.

Evoking the nameless story of obeah pregnancy that Petrona first recounted, Petrona's initial explanation for her pregnancy was that she had been ‘obeahed’ by Mr. Santiago, the bush doctor/CNA in Petrona's village with whom she was to work closely at the rural health clinic. Petrona revealed that Mr. Santiago, a Mopan-speaking Maya in his early-40s, had made sexual advances, which she had refused. Petrona subsequently perceived Mr. Santiago's attitude shift to an unwillingness to work with her that similarly spoiled her credibility as a midwife. He stopped informing her of the mobile prenatal clinic schedule and he refused to share needed supplies like latex gloves. Petrona believed that Mr. Santiago's attitude negatively influenced the village women toward her TBA practice. Ultimately, Petrona accused Mr. Santiago of trying to shame her in the eyes of the community by impregnating her through obeah.

When Petrona had first brought obeah pregnancy to my attention, I tried to ascertain a medical opinion on the condition. Nurse Ical, also a Mopan-speaking Maya, aged 39, offered the following explanation: an obeah pregnancy was not a true pregnancy but was usually a case of fibroid tumors that could distend the abdomen as they grew. Often by the time a woman sought out a medical doctor to check the ‘pregnancy’, the fibroid would be too large to remedy without a total hysterectomy – an uncommon operation due to a combination of distance to a medical facility, cultural miscommunication and finances. If left untreated, the fibroid might rupture, causing bleeding and/or death of the ‘pregnant’ woman. Her death would ‘confirm’ the power of the obeah. ‘Well,’ Nurse Ical continued:

I don't believe obeah pregnancy – except for one case, which was my grandmother. Her belly mi swell, swell and you could even see a wiggling under her skin. When she was dying she said to us that something di come out from inside of her. Then a rat come out of her and fluid gush out. Then she take her last breath and she dead. They say that de obeah, but I no know. Maybe.5

Nurse Ical's two interpretations of obeah pregnancy, one biomedical and the other cultural, exemplify how local forms of knowledge permeate, and at times supersede, authoritative understandings of health and illness (Jordan 1997). According to Nurse Ical, fibroid tumours account for some obeah deaths and his mention of a ‘rat’ may have referred to a hydatidiform mole, a chromosomally abnormal pregnancy that grows in place of the placenta and must be removed through dilation and curettage. However, in Toledo women rarely seek prenatal care until the second or third trimester and a molar pregnancy usually self-terminates in a spontaneous first trimester abortion. The passing of unidentifiable tissue without acknowledging the possibility of a ‘true’ pregnancy may validate the compelling power of obeah. In the body of women, belief in the supernatural joins biomedical explanation to become part of the profoundly mundane ‘ways of knowing the world’ (Khan 2004, 103).

As a nurse – and a Maya – Nurse Ical's admitted belief in his grandmother's obeah pregnancy helps to illuminate the darkness surrounding the consequences of stratified reproduction (Colen 1995) in southern Belize, where for some women obeah pregnancy offers a culturally permissible explanation for socially stigmatised sexual behaviours that can only be remedied through abortion – or suicide. Although Nurse Ical makes no mention of obeah pregnancy being used to mask this practice, his silence unwittingly perpetuates the stigma surrounding premarital sexual liaisons and illegal abortion (Layne 1997). The threat of shame socially obliges women like Petrona to shroud their unwanted pregnancies in allegations of obeah, such that even after Petrona undeniably underwent surgery to remove a dead foetus from her womb, she continued to proclaim (and believe?) that her virginity had been compromised by obeah.

On numerous occasions I tried to ease Petrona's shame with anecdotes from my own – at times controversial – personal history (cf. Gonzalez 1984). As an unmarried woman living in the USA with my two children from different fathers, who are both racially distinct from my Caucasian ancestry, I am familiar with the emotional discomfort that results from having transgressed societal norms. While I believed myself to have become less of a researcher and more of a human being in her eyes (and maybe more of a unabashed sinner!), Petrona still refused to acknowledge that she had engaged in any sexual activity that could have resulted in pregnancy – until she watched the televised mass. Later that afternoon, Petrona ‘confessed’ to me that she had had sex on two occasions within the last year with a 17-year-old boy. She quickly alleged that he had raped her twice and rationalised her silence by stating that a man – and an underage one at that – would go unpunished. She also claimed that the sexual contact occurred more than nine months before the operation. Thus, she maintained that Mr. Santiago's obeah had caused her to become pregnant, despite an admission of premarital sex.

According to psychiatrist Michael Lewis (1992), ‘The more one can blame an external source the more likely one will avoid feeling shame’ (102), and throughout our conversations Petrona continued her accusations of both rape and obeah. By blaming the young boy and Mr. Santiago for the shame she experienced as a result of her premarital sexual activity and unwed motherhood, Petrona refused to accept the responsibility for her reproductive situation to which she was culturally obligated – whether the sexual encounter was forced or not. Petrona said that she noticed her stomach was swelling, but she continued to menstruate. Although the bleeding was likely to have been caused by the low-lying placenta, Petrona was not alerted to seeking gynecological care because she believed that her condition was caused by the supernatural forces of obeah for which biomedicine has no treatment. This might also explain why she went into labour alone in her village.

However, it would also make sense that Petrona's training as a TBA would have permitted her to feel somewhat confident that she could deliver her own baby. Placenta previa accounts for why Petrona experienced vaginal bleeding throughout her pregnancy, but without a sonogram it would have been impossible to ascertain the position of the placenta to know if a vaginal birth was possible. Petrona's training as a TBA should have indicated that bleeding during pregnancy was a danger sign for which she should seek medical attention, but she could have been trying to convince herself that she was spontaneously aborting. Maybe, in fact, she was taking an abortifacent, and thus when she went into labour she perceived this as a completion of the induced abortion. Or maybe Petrona was trying to give birth clandestinely with the intention of absolving her shame through one final act of denial: leaving the baby for dead in the bush.

While I lived in Toledo there were whispered allegations that some women ‘dash’ (dispose of) their unwanted babies upon birth. Often these rumours circulated along with suspicions of incest. Thus, when the news of Petrona's pregnancy began to spread among the local hospital personnel, incest was the first explanation that helped outside observers to make sense of her secrecy. The laws governing marriage in Belize prohibit unions between a father and his daughter or step-daughter and between full and half siblings (Government of Belize 2000). Nonetheless, the prevalence of extra-legal father/step-father sexual abuse and the sexual exploitation of children by their caregivers was addressed by United Nations Children's Fund UNICEF in its 2004 analysis, which stated that ‘many girls are being sexually abused with the knowledge – and, likely, ‘consent’ – of the parent’ (UNICEF 2005, 85). So widespread is this recognised social problem that it was even the subject of an instructional comic book entitled D(B)addy, published by a local NGO, which began with the story of a young girl raped by her step-father, who asserted his patriarchal authority after forced intercourse with the rhetorical question, ‘Who your daddy now?’ (Youth Empowerment Services 2003, 4). Indeed, there was a cultural understanding prevalent among the many men that I spoke to in Toledo that they had a patriarchal right to marital (including common law) property, which explains and may even justify – or allow them to – ‘turn a blind-eye’ to father-daughter incest. Boisterous allegations of sexual encounters between these relations were also made by women in the community when discussing clandestine out-of-wedlock pregnancies, some of which were terminated through illegal abortion or the pregnant woman's death.

According to government reports, child abuse and sexual exploitation go unreported – even by the officials who have a duty to report such crimes (UNICEF 2005). It has been further suggested that the environmental constraints of Toledo, ‘would make it difficult to follow-up on reported cases and to detect unreported ones’ (Government of Belize 2004, 11). However, Nurse Ical clarified that, ‘No one wants to get involved because people talk, and it might cause trouble.’ Such was the case of an 18-year-old epileptic, retarded and wheelchair bound Kekchi-speaking Maya woman from one of the nearby villages, who was brought to the hospital by her mother because of her uncontrollable screaming. Nurse Ical immediately diagnosed that she was in labour and whispered to me, ‘She is pregnant again for her father’. Pointing to a five-year-old girl who quietly stood next to the two women, he continued, ‘See that little girl there? That is her mother [the woman in labour], and her father is the same for her mother.’

According to Nurse Ical, the family lived outside the main village area where the man routinely raped his daughter and battered his wife (on this day her face was bruised purple). Although he admitted to the incest after the birth of the first child, his wife did not press charges. Nurse Ical told me that once this second baby was delivered, he would refer the disabled woman for a tubal ligation to avoid future pregnancies. If she could no longer get pregnant, she would avoid any future public display of her socially deviant reproductive activity. Likewise, the hospital staff would escape public association with these aberrant behaviours. This solution offered the young woman some protection from the shameful gaze of others, but it would not protect her from future incestuous rapes or prevent her from feeling the private shame that stemmed from having transgressed gendered normative behaviour.

Responsible reproduction

In southern Belize, pregnancy – or, more commonly, avoiding pregnancy – is a woman's responsibility (McClaurin 1996, 74). A woman can assert her legal right to child support, but outside the courtroom a man is rarely held accountable when a woman becomes pregnant. Often he will deny his involvement if the couple are not married and even a married man might assert that he is not the father if the physical appearance of the child can be questioned or if the wife has been accused of, or observed to be having, an extra-marital ‘sweetheart relationship’ – the pervasive local form of serial monogamy common to the Caribbean region.6 Women in Toledo often refer to the relationship between children and their fathers as one of possession: ‘De baby fuh he’ [The baby is for him]. However, this assertion of paternal obligation and responsibility cannot enforce its acceptance. In a sexually active environment characterised by unequal gender obligations, Catholic influenced anti-abortion rhetoric and low use of birth control, a woman's sexual health and reproduction remain her responsibility.

In this setting, suicides are commonly discussed, as are botched abortions that result in death. During my fieldwork, two young women rumoured to be pregnant died of purported suicide from ingesting poisonous substances. There is, however, no statistical evidence that can accurately tally the number of girls who die from drinking Gramoxone herbicide in an attempt to ‘off’ a pregnancy, or those who die from excessive bleeding after drinking bush medicine or an off-label prescription drug clandestinely provided by a medical doctor. Abortions are among the leading causes of hospitalisation for women and, given the stigma surrounding the illegal procedure, death from abortion is often reported as ‘a complication of pregnancy’ (Pan American Health Organization 2001).

Nurse Lee, the aforementioned head of the maternal and child health programme and the direct supervisor of the TBAs in Toledo, was not interested in knowing whether Petrona had been raped by an underage boy, had engaged in consensual premarital sexual intercourse or if obeah had caused a foetus to grow in her womb. She was concerned that Petrona had been pregnant and did not act responsibly by seeking prenatal care. As a TBA, Nurse Lee emphasised that Petrona should have known the importance of antenatal care and ‘joined clinic’ in the first trimester. To make matters worse, Nurse Lee believed that Petrona's position as a TBA made her a model for the pregnant women in her community; if she could not follow safe motherhood practices during her own pregnancy, how could she be expected to advise others to do so? For this reason she wanted Petrona to relinquish her position as the village midwife.

Nurse Lee also used Petrona's actions to claim the superiority of the TBAs trained by the Belizean MOH over those trained by a foreign NGO. When I first approached Nurse Lee to discuss my interests in conducting research with TBAs, she immediately made a distinction between ‘her’ TBAs, who worked one-on-one with a Ministry nurse, and the TBAs (such as Petrona), trained by international NGOs like Gift, in a large classroom setting. According to Nurse Lee, ‘her’ TBAs were better qualified to attend deliveries and were more integrated into the Belizean MOH's local public health programme.

Nurse Lee was not the only one skeptical of programmes undertaken by ‘foreigners’. Miss Mavis, a Garifuna woman aged 44, who had a long professional history with the MOH, commented thus on Gift's training programme:

These types of organisations, they come in and blow their trumpet, and then they leave the people hanging. They don't recognise the importance of working with the [Belizean] system. Because once they are gone, these people [the trainees] need the support of the existing establishment.

The former director of the Ministry of Human Development, another Garifuna woman also in her 40s, corroborated:

These people come here with their ideas of what they think needs to be done. But what they don't understand is that we have a system. And the system works because we have made it work. … Outside experts – they all come and go and nothing changes.

Both women emphasised the importance of working with the existing institutions to ensure sustainability and rapport once the outside resources are gone. Similarly, Nurse Lee focused on Petrona's disengagement from the local system as well as the near statistical increase in maternal death that would have resulted from her misconduct. Meanwhile, Petrona remained preoccupied with cultural impropriety, Catholic sin and shame.

Penance

I eagerly accompanied the mobile clinic to San Tómas after Petrona had returned from her post-operational recuperation at my house. I wondered if she would continue to perform her duties as a TBA and assist the rural health nurse at the mobile prenatal clinic. Of course, I was wearing two hats: I was very friendly with Petrona and also quite close to the MOH personnel who censured her conduct. I felt obliged to inform her that Nurse Lee was adamantly opposed to her continuing as a TBA, but emphasised that she needed to discuss this with Nurse Lee, who candidly told me that she was deciding how to best broach the subject. Nurse Lee was quite aware of the psychological impact of the situation and was fearful that Petrona might commit suicide if confronted with the consequences of her actions.

Arriving in Petrona's village, I felt somewhat awkward to be greeted at the rural health post by the CNA/bush doctor who may or may not have been aware of his role in the life altering course of events for which Petrona held him responsible. Feigning ignorance, I outright asked Mr. Santiago if Petrona would be assisting at the mobile clinic. His response was to quietly point me in the direction of her house as he lowered his head and turned away – quite possibly out of shameful admission or otherwise to simply signal that our conversation had ended.

Petrona was aware that the mobile clinic would be arriving that morning, but she did not expect to hear my voice calling from her front yard. In the course of our conversation I asked if she had done any deliveries since the operation, to which she replied that she was still feeling weak. However, she was providing prenatal care for her brother's wife who was eight months pregnant.

Less than a month later, Nurse Lee was again in an uproar. Rumour was circulating around the hospital staff that Petrona had attended her sister-in-law's birth. Nurse Lee had never gone beyond her discussions with me to stop Petrona's midwifery practice, and there was much heated debate among the hospital staff about whether or not Nurse Lee had the authority to sanction Petrona, or if it was even the right thing for her to do. Some felt Petrona should not be penalised for her actions, which were based on cultural and social pressures. Some even acknowledged that they themselves played a part in perpetuating these pressures. Others cited the objectives of maternal health initiatives and believed it to be even more dangerous to deny the community of a trained birth attendant. Some did not see how Petrona could be prevented from practicing since TBAs were not on the MOH payroll and could not, therefore, be ‘fired’.

A few weeks after these unofficial discussions in the hospital's hallways, the Ministry's mobile clinic returned to San Tómas. Petrona eagerly went to help only to be informed by the rural health nurse that she was not allowed to assist until she spoke to Nurse Lee. According to Petrona, Nurse Lee said that her situation was being deliberated by the Ministry's head office and that she would need to await further instruction before being allowed to deliver babies. Petrona had no recourse but to stop her practice and wait.

Her reaction to the news, however, was quite different from what Nurse Lee had anticipated. Far from appearing sullen or suicidal, Petrona was repentant – and quite angry. Evoking a religious sentiment similar to the one she expressed while recuperating at my house, Petrona accepted, ‘I must really be a sinner’. Her tone then changed to one of acknowledging human nature and atonement. ‘But are they perfect?’ she exclaimed. ‘I no 'shame again. Yes, I made a mistake, but why can't I be forgiven?’ In Petrona's mind, her mediated penance during the televised mass atoned for her sins and absolved her shame. She acknowledged that she, similar to other practicing Catholics, committed a sin that could be forgiven upon confession. Moreover, she did not understand Nurse Lee's continued shaming discourse, since it was Petrona's contention that her pregnancy was caused by the supernatural forces of obeah. Whereas Nurse Lee emphasised Petrona's lack of maternal responsibility with respect to the public health mandates that a trained TBA should, in theory, have learned to uphold, Petrona's personal shame derived from her premarital sexual activity and her ‘pregnancy’ – not the fact that she did not attend the prenatal clinic.

I listened as Petrona wrestled with Nurse Lee's decision, and I remain conflicted over my silence in response to her final rationalisation. Clearly demonstrating an unwavering commitment to her community and a powerful belief in cultural practices – yet likely indifferent to her biomedical training and the Ministry's protocols for reproductive health – Petrona adamantly declared, ‘Well, even if they tell me not to do any deliveries, I can still do prenatal exams. If the baby's good, they can deliver with their mothers. I can still help the people like that.’

Conclusion

In the Toledo District, reproduction is stratified (Colen 1995) according to relative understandings of propriety, principally shaped by religious doctrine and socialised in large part through the shaming practices of public reprimand and physical punishment. Despite the often involuntary nature of women's sexual experiences and the limited access to contraceptive technologies and abortion, engaging in sexual activity that results in pregnancy is considered an agentive and intentional act. A cultural understanding of personal responsibility places the burden of reproduction on women who must utilise the cultural scripts available to them to make sense of and cope with their – at times – undesirable and often shameful situation.

By looking closely at Petrona's experience surrounding her pregnancy, I argue that allegations of obeah serve to disguise or render invisible a socially unacceptable reproductive state. Although some conditions that physically manifest as a pregnancy, or certain reproductive-related deaths of unknown material origin, may be labeled obeah pregnancy, Petrona's case serves to exemplify how a ‘true’ and medically viable pregnancy can be reinterpreted according to competing forms of knowledge about illness and disease that rely upon notions of supernatural causality. In this context, obeah is part of the apparatus used to discipline women's reproductive activities. Despite its typically malevolent nature, in this instance obeah buttresses the system rather than opposes it, by allowing women a way out of their reproductive problematic while supporting the hegemonic representation of female sexuality. For Petrona, the power of obeah, as a culturally recognised supernatural force, ‘confirmed’ her shameful condition while it assumed her accountability.

It is impossible to ascertain whether or not Petrona tried to abort or if she intended to clandestinely birth her baby and then allow it to die. Neither of these possibilities is unheard of in the pervasive gossip that surrounds women's sexual activity in Toledo. Nevertheless, even after a dead foetus was removed from her womb, Petrona maintained that she did not know she was pregnant. While it is not uncommon for women to hide their pregnancies until they can successfully terminate them, what makes Petrona's denial unique is her position as a trained TBA who, in theory, should uphold and follow the maternal and child health protocols implemented by the Belizean MOH; instead, in practice, she adhered to a stronger set of cultural imperatives that nearly killed her.

It was Nurse Lee's contention that it was Petrona's improper – and foreign – TBA training that resulted in her near-miss with death. She argued that if Petrona had sought out the prenatal care provided by the Belizean MOH, which she should have been trained to uphold and value, her pregnancy would not have resulted in a cesarean stillborn. In other words, placenta previa would have been diagnosed and Petrona could have prepared for a non-emergency cesarean delivery instead of an emergency transfer while in a state of shock from blood loss. In her tirade against foreign involvement in Belizean affairs, Nurse Lee was ignoring the local societal pressures that drove Petrona to hide her pregnancy from her community, the MOH and even from herself.

Furthermore, I suggest that Petrona's TBA training may have actually increased her confidence in her own ability to self-manage her pregnancy and delivery, which she did quite well until placenta previa altered the course of events. Even when Nurse Lee informed Petrona post-pregnancy that she could no longer deliver babies, Petrona's self-assured comments regarding her ability to ascertain foetal positioning and her desire to continue to provide this service indicate that she felt quite comfortable with her prenatal skills and valued the importance of prenatal care. However, Petrona's story speaks to the social realities of pregnancy, childbirth and midwifery practices against which the statistical evaluations of population, mortality rates and the ‘success’ of training programmes should be weighed. In conclusion, I argue that it was Petrona's internal shame – which she transformed into the power of obeah –that disallowed her from seeking maternity services. This gendered risk, stemming from the social stigma associated with unwed motherhood, far outweighed even the risk of dying from the perinatal complications that thwarted Petrona's secretive plans for a delivery in the bush.

Acknowledgements

I thank Petrona for trusting me with her story. I can only hope that this retelling will ease the shame for future generations. And thank you to Rayna Rapp and Aisha Khan, who offered invaluable insight throughout this paper's earlier stages. The Wenner-Gren Foundation generously funded 12 months of fieldwork.

Notes

^1. Pseudonyms have been used throughout to protect the identity of the individuals cited.

^2. Placenta previa is a condition that occurs when the placenta implants near the internal cervical os, growing to cover it, thus precluding a vaginal birth.

^3. As of 2010, the Belizean MOH has complied with the World Health Organization's framing of family planning as a public health intervention that will help to reduce maternal mortality and now distributes a wide range of contraceptives to its population free of charge (see WHO 2005).

^4. Common law unions are widespread throughout the Toledo District. To avoid public scrutiny, women usually state that they are ‘married’ when in such relationships. It is unclear from the Census data if women reported as ‘married’ were in actual legal union or in a committed long-term relationship. As such, the numbers of unwed pregnancies may be higher than what is reported by the Central Statistical Office.

^5. McClusky (2001) asserts, ‘Maya frequently use “maybe” even if they are certain. In fact, it sometimes signals great certainty, but an uncomfortable topic’ (278).

^6. Influenced by Catholic avoidance of divorce, an extra-marital sweetheart relationship indicates a permanent, or sometimes temporary, termination of sexual relations while maintaining other kinds of spousal obligations.