Pregnancy outcomes, site of delivery, and community schisms in regions affected by the armed conflict in Chiapas, Mexico
Section snippets
Background
Since 1994, the state of Chiapas, Mexico, has been the site of low-intensity armed conflict between the Mexican government and an insurgent force known as the Ejército Zapatista de la Liberación Nacional (the Zapatistas). This conflict overlaps and exacerbates longer-standing local disputes over land tenure, religion, and other issues (Eber (2001), Eber (2003); Leyva Solano, 2003; Womack, 1999a). Although deliberate killing of civilians has occurred as a result of the Zapatista conflict, e.g.
Methods
Study design: This was a cross-sectional, population-based household survey supplemented by semi-structured interviews.
Study population: We consulted published reports and regional experts in health, human rights, and Chiapanecan history (Table 1) in order to select the three (of nine) Chiapanecan administrative regions most adversely affected by the Zapatista conflict, and their most affected municipalities (Table 2). We used census data (Instituto Nacional de Estadística, Geografía, &
Community participation
Of 54 communities primarily selected for inclusion, 37 (68.5%) were surveyed. Of 18 replacement communities, 5 (27.7%) were surveyed. However, 6 of the 18 were not approached because recruitment goals for their community types had been reached. Non-response occurred primarily because communities or factions suspected the study team of sympathizing with rival factions or parties, although 1 community was found to have disappeared entirely during the conflict and 2 more could not be reached
Discussion
Observed mortality ratios in the study population were high, and both mortality and site of delivery were significantly associated with descriptors of local conflict (both inter-party and intra-community), even in multivariate analyses that also included other socioeconomic and demographic factors.
Observed maternal and perinatal mortality ratios were substantially higher than those recently reported at Mexican national and state levels. The maternal mortality ratio for 1997 was reported as
Conclusions
We observed that maternal and perinatal mortality ratios in the study population were substantially higher than those officially reported for the state of Chiapas and for Mexico as a whole, and that mortality was associated with intra-community and inter-party political and religious divisions, some of them violent, even in analyses adjusted for other known risk factors. Observed mortality was also clearly associated with lack of access to emergency obstetric care. The discrepancy between the
Acknowledgments
The authors are grateful to the residents and leadership of all of the study communities for their participation, to the many Chiapanecan experts who provided them with essential background information, and to Alicia Ely Yamin; Victor Penchaszadeh; and Vincent Iacopino for their advice. The authors are indebted to Roberto Solís Hernández, Alejandro Flores Hernández, Herlinda Méndez Santiz, Blanca Luz Coello Zepeda, Juan Manuel Canales, Jonathan Kirsch, and Kerri Sherlock, for their help with
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