Home-birth emergencies in the US and Mexico: the trouble with transport.

Proponents of the global Safe Motherhood Initiative stress that primary keys to safe home birth include transport to the hospital in cases of need and effective care on arrival. In this article, which is based on interviews with American direct-entry midwives and Mexican traditional midwives, I examine what happens when transport occurs, how the outcomes of prior transports affect future decision-making, and how the lessons derived from the transport experiences of birthing women and midwives in the US and Mexico could be translated into improvements in maternity care. My focus is on home birth in urban areas in Mexico and the US. In both countries, biomedicine and home-birth midwifery exist in separate cultural domains and are based on distinctively different knowledge systems. When a midwife transports a client to the hospital, she brings specific prior knowledge that can be vital to the mother's successful treatment by the hospital system. But the culture of biomedicine in general tends not to understand or recognize as valid the knowledge of midwifery. The tensions and dysfunctions that often result are displayed in midwives' transport stories, which I identify as a narrative genre and analyze to show how reproduction can go unnecessarily awry when domains of knowledge conflict and existing power structures ensure that only one kind of knowledge counts. This article describes: (1) disarticulations that occur when there is no correspondence of information or action between the midwife and the hospital staff; and (2) fractured articulations of biomedical and midwifery knowledge systems that result from partial and incomplete correspondences. These two kinds of disjuncture are contrasted with the smooth articulation of systems that results when mutual accommodation characterizes the interactions between midwife and medical personnel. The conclusion links these American and Mexican transport stories to their international context, describing how they index crosscultural markers, and suggest solutions, for "the trouble with transport."