Pascale Hancart Petitet

Résumés des communications scientifiques

2004 – avril 2011

2011

Karaoke Hostesses in Phnom Penh Negotiating Gender Identities in

Contemporary Cambodian Society SWU-Social Sciences Conference Asian
Identities: Trends in a Globalized World February 9th-11th, 2011 Bangkok,
Thailand.

In Cambodia, young women living in poor rural areas come to the capital city, in
order to find an activity able to meet their needs and those of their families.
Some find a job as hostess bar karaoke. This activity induced physical and social
changes and tends to modify their relation to their femininity, their health and
their sexuality. As they also eventually sell sex, they are considered by public
health actors as "vulnerable populations", and they are targeted for prevention
and care activities in reproductive health and HIV. This contribution seeks to
explore how, far from being “victims”, these young women deal with their new
role and how they implement care practices related to HIV prevention and
unwanted pregnancies. The issues raised highlight how social and spatial
migrations lead those women to build new identities while challenging and
negotiating gender norms and codes in the contemporary Cambodian society.

2010

Des matrones face à la mortalité maternelle dans les pays du sud. Construction
des rôles et négociation des pratiques. Colloque international interdisciplinaire
sur la mortalité maternelle en Afrique Sub-saharienne: Mieux comprendre pour
agir », Université Cheikh Anta Diop, 13 au 16 Décembre 2010.

Avec le présupposé que la biomédecine était capable de prévenir la majorité des

morts maternelles, l’une des trois recommandations, formulées en 1987 par «
l'Initiative Maternité Sans Risque », était de former des matrones. Néanmoins,
ces formations réalisées durant trois décennies sont décrites comme étant
majoritairement un échec. Pourtant, les nombreux travaux des sciences sociales
permettent de poser le débat relatif à la pertinence de la formation des matrones
en d’autres termes. Ainsi, le débat relatif à la pertinence des formations des
matrones pour réduire la mortalité maternelle est loin d’être clos ; de
nombreuses questions restent en suspens. Comment s’élaborent les rôles des
matrones aujourd’hui ? Dans quelles mesures les politiques sanitaires autour de
la naissance élaborées au Nord sont réinterprétées dans les pays du Sud par les
acteurs en charge de programmes localement, par les acteurs de soins
responsables des formations des matrones, par les matrones elles-mêmes, et par
les personnes qui ont recours à leurs services. L’objectif de cette communication
est nullement de remettre en cause les effets bénéfiques de la bio médicalisation
de l’accouchement mais de montrer, comment, et pourquoi se construisent les
pratiques des matrones et les discours dont elles sont l’objet actuellement.
What makes women’s life sustainable? Investigating on abortion issues in
Cambodia. East Meets West in Pursuit of a Sustainable World Asian Conference
on the Social Sciences, June 18-21 2010, Osaka, Japan.

In Cambodia, the abortion law was reformed in 1997. Nevertheless, it does not
guarantee that women can obtain safe abortions. Maternal mortality rate is very
high in this country and it is recognized that 26% of maternal deaths are due to
high-risks abortion practices. Since 2008, under the Millennium Development
Goal 5 Initiative that aims to reduce the maternal mortality rate, various actions
are launched by local authorities, international organizations and NGOs in order
“save women lives” while improving safe abortion access. Caregivers working in
the public sector are receiving training in various places and abortive pill use is
now legitimized. This study aims to document the social construction of safe
abortion in Cambodia while investigating, from various perspectives, what shape
safe abortion policies and practices, and what are its impacts and effects. It is
based on an ongoing anthropological research that takes a look at discourses and
practices of stakeholders, caregivers, and women related to safe abortion. We
examine the international context that frame those policies, discourses, actions
and impacts, the various logics that shape health actors practices while
implementing activities and the inner experience of women while accessing, or
not, to safe abortion services. From theoretical perspectives we aim to document
how maternal mortality issues may be analyze as a construction of new forms of
bio legitimacy that may or not contribute to make women lives sustainable in
Cambodia.

2009

Vasectomy, Renegotiation for Masculine Identities? Anthropological perspectives

on male reproductive technology in Cambodia.” International conference (Re)
Figuring Sex: Soma technical (Re) Visions, 19-20 November 2009. Sydney
Australia

Vasectomy is a surgical procedure performed to men that aims to occlude the

vas deferens in order to achieve permanent sterility. Since the 1970’s, this
method has been promoted by Feminists and Scientifics as a birth spacing "equal
sharing of responsibility". This paper aims to investigate how users, caregivers
and stakeholders’ representations of masculinities influence practices around
vasectomy in Cambodia. Ethnographic investigations were conducted in urban
and rural areas with couples’ whose men undergo for vasectomy, caregivers in
charge to implement counseling and surgery procedures, social workers
responsible to recruit candidates and vasectomy program directors. Broader
interviews related to contraceptives uses were carried out in 2008. The analysis
enlightens the representations of masculinities that steer health stakeholders and
caregivers to promote vasectomy and that lead men to undergo this surgical
procedure. In Cambodia, the use of modern contraceptives is very low. The
“male involvement in population control” recent concept developed by
international agencies and “simplicity and cost effectiveness” biomedical rhetoric
related to male sterilization versus female sterilization shape reproductive health
local policies and practices. Sometimes, it leads stakeholders and caregivers to
opt, to some extent, for coercive method in order to achieve their objectives.
From this perspective, we describe, firstly, how during the counseling session
preceding surgery for instance, no other option than to acquiesce is given to the
“targeted” man. Secondly, we present a biographic portrayal of a “vasectomy
community motivator” employed by an international organization. Thus, we
describe and analyze which factors led him to undergo for vasectomy. Lastly,
new representations of masculinities that male sterilization implies for the user
will be discussed. The aim of this paper is to explore how the image of man as
"caring and responsible" in matters of contraception is reflecting contemporary
understandings of the body as the incarnation of historically and culturally
specific discourses and practices on masculinities in Cambodia.

Social Construction and Social Production of Abortion. Some insights from

Cambodia. International Conference of the Society for Medical Anthropology of
the American Anthropological Association. September 24 - 27, 2009. Yale
University.

In Cambodia, despite the implementation of governmental reproductive health

care activities since 1994, contraception prevalence rate remains very low. Many
women undergo chemical or mechanical abortion. Indeed, abortion has been
legalized in Cambodia in 1997; however there is a lack of awareness regarding
the legality of abortion and a lack of provision of safe abortion services. Unsafe
abortion remains one of the most common causes of maternal death. Thus, we
may wonder why, how and to which extends cultural values, gender norms,
social organization of care and political will to tackle the problem head-on as well
as individual experiences and attitudes regarding unwanted pregnancies shape
abortion practices. We will investigate those issues in cross-crossing various
perspectives levels. Firstly, we will give some historical elements related to
abortion legalization and policies in Cambodia. Secondly, we will analyze how
social organization of care shapes legal and illegal abortion practices. Thirdly, we
will describe determining factors that lead women to seek abortion. Finally, we
will investigate how abortion event makes sense in their reproductive lives. Thus,
our findings may raise relevant issues for public health perspective, provide
mirrored views on Cambodian Contemporary Society as well as bring various
theoretical insights for anthropology.

“They only have to use condoms!” Social aspects of contraceptives use amongst
ARV users in Cambodia. Research perspectives. International workshop on The
Impact of HIV/AIDS and its Treatment in Asia Chiang Mai, Thailand, 19-21
February 2009

Aim: According to WHO's Medical Eligibility Criteria for Contraceptive Use, most
of contraceptive methods are considered to be safe and effective for HIV positive
women. However, in Cambodia, we found that it is generally assumed by
caregivers and PLWA representatives that people leaving with HIV/Aids only have
to use condoms. The aim of this paper is to describe firstly, caregivers and
PLHWA’s reason for not considering other contraceptive options for people on
ART. Secondly, we will investigate various social factors that lead people under
ART to use other birth spacing methods like contraceptives pills, Depo-Provera
injection, contraceptive and abortive “Chinese pills” as well as abortion.

Methods: The study is based on an ongoing ethnographical research conducted

with the project “HIV, HVB, HVC Transmission and Reproductive Health Care in
Cambodia, An anthropological approach” (ANRS 12102). Observation and
interviews have been conducted in urban areas with 20 women living with HIV, 5
PLWHA representatives and 5 caregivers. Broader interviews related to
contraceptives uses have also been conducted with 130 people (mainly women
and 25 caregivers).

Results: The analysis shows various factors that lead caregivers and
representatives of PLHWA not to consider methods different from condom for
birth spacing practices amongst people under ART. Those factors are related to
the consensus about the need of dual protection for people living with HIV, to
medical assumptions that are not validated anymore in the scientific community
(drugs interaction leading to decrease efficacy of ARV treatment) and to social
categorizations of patients (condoms user described as the good ART patient,
reproductive health care refusal for PLHWA). Our data suggest also that many
other factors lead people under ART not to use condom. Those factors are related
to the discomfort with male condoms expressed by people and to women
difficulties to negotiate safer sex. Various common social representations on
contraceptives secondary effects or lack of knowledge on contraceptives drugs
lead also some women to go for abortion. Finally, the fear to talk about such
subject with caregivers appears also to be an important point to consider as it
leads ART patients to hide their contraceptive practices to caregivers.

Discussion: From a theoretical point of view, this study suggests relevant

hypotheses for the anthropology of reproductive health. For example, we may
consider why, how and to which extend social norms in the field of reproduction
are build and interpreted in the Cambodian context of AIDS. From the
perspective of applied research, those findings demonstrate the necessity to
consider seriously the need of contraception for people undertaking ART. This
issue raises a problem for public health, as many women go for unsafe abortions
or other treatments like contraceptive and abortive “Chinese pills” (whose effects
on ARV treatment have not yet been documented). From an ethical point of view,
there is a need for people under ART, as for everybody, to receive accurate
information on contraceptive methods and to get benefit from counselling
sessions that will help them choosing the best adapted one.

2007

Hancart Petitet P, Samuel NM, Desclaux A, Pragathi « Missed opportunities for

HIV PMTCT: A case study in South India . Abstract n°61 International
Conference Aids Impact Marseille 1-4th July.

Aim: In India, PMTCT programs are available at tertiary hospital level and
numerous women, particularly, when living in remote areas do not have access
to those services. Others, living in cities are not receiving the correct information
about PMTCT, or are not able to follow the entire protocol required by caregivers.
For various reasons some women are lost of for follow up. The aim of this paper
is to describe the various social factors that do contribute to missed opportunities
for PMTCT.

Methods: The study is based on an ethnographical research conducted in rural

areas with women and in a public hospital where PMTCT and HAART programs
have been set up. In- depth interviews have been conducted with women
attending antenatal care, involved in PMTCT activities, or receiving HAART
treatment. Interviews were also held with healthcare providers.

Results: The analysis of factors for transmission shows the intricacy of various
social factors that limit women’s access to PMTCT. For example: social
categorization of patients done by health care givers when deciding whom to test
or not; economical factors that limit the possibility of women to follow the rules
required by protocols; social factors that shape discrimination and stigma of HIV
infected people; inadequacy of ethical norms edited by international health
institutions that are sometimes difficult to implement in some contexts. Some
factors are related to the poor living conditions of women in rural areas, others
are related to relationships between pregnant women and the health system,
mainly through their interactions with health workers.

Discussion: These data are relevant to identify the missed opportunities for
PMTCT regarding the integration of a continuum of surveillance and control of
PMTCT. The presentation will describe and analyze factors that enhance the
continuum of care regarding PMTCT and identify factors that facilitate and hinder
efforts to prevent and treat HIV-related diseases in mothers and children in
India.

Hancart Petitet P, Samuel NM, Desclaux A, Pragathi « Sociocultural factors of hiv

transmission during delivery in India. » Abstract n°60 International
Conference Aids Impact. Marseille. 1-4th July.

Aim: In India, programmes for Prevention of HIV Mother-to-Child Transmission

(PMTCT) have been implemented in some public health structures since 2001.
However, the majority of women do not access these programs since many
deliveries occur at home, with the help of Traditional Birth Attendants, or in
Maternity wards that do not develop MTC prevention. This is important not only
for infants but also for women’s health, since the context of pregnancy and
delivery is the main opportunity in India for women’s information on HIV and
testing. The aim of this paper is to describe factors that favour or hinder mother-
to-child transmission and iatrogenic transmission at field level and according to
delivery settings.

Methods: The study is based on an ethnographical research conducted in four

birth settings: at home with a Traditional Birth Attendant, in a district clinic
without PMTCT program, in a public hospital with a PMTCT program, in a highly
specialised HIV centre. In depth interviews have been conducted with women,
healthcare providers and Traditional Birth Attendants.

Results: The analysis of factors for transmission shows the intricacy between
biological and social factors, such as the length of labour due to poor
management of delivery in some health services for women from low social
status. In each setting, some factors are specially related to HIV (such as
women’s low level of knowledge about AIDS or unavaibility of HIV testing), when
others are not (such as high frequency of C-sections in hospitals and private
clinics). Most factors are related to relationships between pregnant women and
the health system, mainly through their interactions with health workers.
Discussion: These data are relevant for the on-going debate about the
involvement of Traditional Birth Attendants in decentralization of PMTCT, which
meets the issue of changes in women’s roles in the time of AIDS. They are also
relevant when considering the consequences of delivery for women’s health,
including iatrogenic transmission and opportunities for HIV care, a topic that has
often been neglected.

Socio cultural epidemiology of HIV/ AIDS. A case study in India. International

Seminar. Medical Anthropology as a tool for Public Health. University
Heidelberg. 9-11 May.

In Southern India, HIV MTCT programs have been started in some governmental
hospitals and by some NGOs but it exist neither in private clinics nor in rural
areas where deliveries are conducted at home by the so called “Traditional Birth
Attendants”. In such context, the distance that separates HIV MTCT
recommendations of International Health Organizations from the actual delivery
practices at home may be viewed as an extremely fertile field of study of the
diverse social factors which condition the actual implementation of the envisaged
safeguards.
The notion of MTCT has two specificities. First, the transmitter defines this mode
of transmission: the mother. Other modes of HIV transmission are defined by
sexual behaviour, blood transfusion or drugs injection. The MTCT define also
three modes of transmission, the pregnancy, the delivery and the breastfeeding.
Thus seems to show the responsibility given to the mother related to the HIV
transmission to her baby. The MTCT concept seems to give to the mother a
major role as a source of transmission. However, the HIV MTCT rate are also due
to various individual, collective, institutional and contextual factors around the
pregnancy and delivery that I propose to describe in using the conceptual tools
proposed by the socio cultural epidemiology.

« Naissance et VIH en Inde du Sud : conflits, questions d’éthique et

méthodologie ». 10èmes Ateliers Jeunes Chercheurs en Sciences Sociales
Pondichéry, 27 février - 2 mars 2007. Conflit, négociation, coopération.
Enjeux et méthodes pour aborder les rapports sociaux en Asie du Sud.

Aujourd’hui en Inde, pour de nombreuses femmes des zones rurales le sida reste
une maladie peu connue. La plupart ont entendu parler de cette maladie.
Cependant peu connaissent les modes de transmission du VIH et les moyens de
s’en protéger. Par ailleurs, les personnes infectées par le VIH sont souvent
victimes de stigmatisation et d’actes de discrimination. La faible réponse initiale
du gouvernement face à l’épidémie, sa résistance face aux mises en garde des
institutions internationales quant à la diffusion d’une épidémie indienne à VIH et
le maintien de son discours moralisateur et conservateur sur l’épidémie auraient
retardé la mise place des actions nécessaires. La position gouvernementale est
peu claire. L’étendue de l’épidémie ne fait pas non plus consensus. Je propose de
rendre compte de certains aspects conflictuels autour de la lutte contre le sida en
Inde du Sud ; d’abord selon du point de vues des femmes d’un village des
environs de Pondichéry, puis selon une perspective plus large, à l’échelle
nationale. Enfin nous verrons comment l’accès à un programme de réduction de
la transmission mère-enfant du VIH est aussi une source de conflits divers pour
les patients et pour les soignants chargés de sa mise en œuvre. Cette
ethnographie des conflits propose donc une lecture des normes, des valeurs, des
règles éthiques et des intérêts divers que l’épidémie de sida, « réformateur
social », vient révéler.

2006

« Rencontre des savoirs autour de la naissance, les cas des matrones au Tamil
Nadu ». séminaire organisé par l’Association des Jeunes Etudes Indiennes,
Savoirs et savoir-faire dans le sous-continent indien accès, transmission et
enjeux. 16 novembre, EHESS, Toulouse.

Dans les pays du Sud, les matrones sont la cible de programmes de

développement variés et l’objet de nombreuses recherches dans le domaine des
sciences sociales. L’Inde ne fait pas exception comme en témoigne l’abondante
littérature scientifique et/ou militante à leur sujet. Les matrones sont l’objet de
discours opposés et contradictoires. Ces derniers conduisent grossièrement à
distinguer les « pro-matrones », persuadés de la nécessité de ces praticiennes
dans le champ de la santé de la reproduction, et les « anti-matrones »
convaincus de la nuisance de leurs pratiques. En adoptant un point de vue
émique, je propose de montrer l’impact de ces formations, ou de leur absence,
sur les pratiques des matrones en Inde du Sud. En effet, face aux pressions
exercées par les représentants locaux du système biomédical et afin de répondre
à la demande des patientes pour des soins « modernes » de l’accouchement, les
pratiques des matrones sont transformées. Ce sont des pratiques variées et
syncrétiques agencées pour tenter de satisfaire les exigences des nouveaux
contextes. Certaines matrones, revendiquent la spécificité de leurs pratiques
comme une variation et une recomposition de celles recommandées et
pratiquées en milieu biomédical. D’autres matrones, voient leur statut de
praticienne et leurs soins dévalorisés. Entravées dans leurs activités
d’accoucheuses, le manque de pouvoir social et d'opportunité de ces dernières
paralysent la réadaptation de leurs pratiques aux nouvelles demandes de soin.
Ainsi, cette communication vise à décrire les causes, la mise en œuvre et les
effets des transformations contemporaines des savoirs et des pratiques des
matrones dans le contexte de la bio médicalisation de l’accouchement.

« State of the Art: PMTCT and Counselling », Second Annual IS-Academy Expert
Meeting on HIV/AIDS, Rethinking HIV/AIDS Preventive Counselling.13-14
November. ASSR, Amsterdam.

As health care practices, counselling is a social practice. Thus, researches on

counselling practices are relevant to describe how those practices take place in
social order. Various aspects of social order may be described. For instance how
counselling session design, implementation, and effects are shaped by gender
issues (ASSR 2006) or how the meaning of counselling is an object of disjunction
between programme providers and patients (Obermeyer 2005). The objective
here is to consider counselling in PMTCT from a broader perspective. I will
present five topics:
1. Local interpretation of the international guidelines on PMTCT counselling
2. Care givers and PMTCT counselling: Who should be counselled?
3. Counselling & Feeding practices: The concept of « choice »
4. Counselling on procreation for HIV+ women. Medical discourses on vertical
risk of transmission
5. Residual risk of transmission of HIV: A “blind stain”
Conclusion: Counselling practices analysis in various cultures and contexts show
that further research are needed in considering counselling as a « social fact »
and as a « cultural interpretation » Until now, researches focussed on counselling
session and on patient care/givers interaction quality and efficacy. The
researches I presented today show that following aspects must be investigated:
Various women interpretation of the medical information on risk and prevention -
Women personal experience of PMTCT (with hindsight distance) - Mediator role
given to women by health system in order to involve their partner in PMTCT-
Women discourses and personal experiences on PMTCT limits and failures - Care
givers social categorisations: Application of various norms depending on
economical or social … background of patients. All those aspects are not only
interesting for social sciences researchers. Their consequences are obvious for
practices adjustment to women needs. In those fields, conditions in North and
South are not so different and a comparative approach might be very useful.

« Programme de prévention de la transmission mère-enfant du VIH en Inde du

Sud :Dilemmes du chercheur et questions d’ethique autour des pratiques
de conseil. Séminaire du CRECSS. L’éthique en anthropologie de la
santé : valeur heuristique, conflits, pratiques. Le 18 Octobre 2006.
MMSH. Aix en Provence

En Inde du Sud les programmes de prévention de la transmission verticale du

VIH sont principalement mis en œuvre par le gouvernement dans des maternités
hospitalières. Certains sont menés par des ONGs. L’observation du déroulement
de ces activités dépend de l’obtention préalable d’autorisations de recherche par
des comités divers au niveau fédéral et local ainsi que de procédures
administratives de longue durée. Pourtant, certaines circonstances ont permis de
contourner ces étapes et de rendre possible une ethnographie d’un programme
de PTME dans un hôpital de district. Une fois sur place, la confrontation aux
contraintes du terrain ont confirmé les dilemmes éthiques envisagés lors la
construction de l’objet d’étude. Comment documenter l’expérience de la
séropositivité d’une femme enceinte lorsqu’un entretien n’est a priori possible
que durant le temps immédiat qui suit la révélation du test VIH, ou au moment
de l’accouchement ? De plus, les modalités d’organisation du conseil par l’équipe
de programme invitent à discuter des agencements possibles, ou non, entre les
principes de l’éthique tels que définis par l’éthique de la recherche et ces
principes tels qu’ils sont interprétés par les personnes supposées les appliquer.
Enfin, les publications et les communications scientifiques produites
ultérieurement à partir de ce recueil de données ne sont pas non plus sans
soulever de nombreuses interrogations. L’objectif de la communication est donc
de rendre compte des questions d’éthique rencontrées par le chercheur (lors de
l’initialisation du projet de recherche, lors de la confrontation des objectifs de
l’étude aux réalités du terrain et lors de la restitution des résultats), et par les
responsables de programme lors de la mise en œuvre des activités de prévention
de la transmission verticale du VIH.
.“HAART as An Opportunity to Improve HIV PMTCT ? An Indian Case Study”
Abstract N°TUPE0824, Poster Exhibition. XVI International AIDS Conference.
Toronto. 13-18 August, 2006.

Background: International public health organizations stand in favour of using

HIV Prevention of Mother To Child Transmission (PMTCT) as an entry point to
Highly Active Antiretroviral Therapy (HAART). The impact of PMTCT activities on
HAART access is currently investigated. In India, few HIV infected pregnant
women know that they are infected by HIV and few have access to free PMTCT.
Recently, public hospitals have started activities to provide free access to HAART.
In such context it appears relevant to explore if HAART could be an opportunity
to improve PMTCT. Method: The study is based on an ethnographical research
conducted in a public hospital in South India. In depth interviews have been
conducted with healthcare providers as well as with female patients involved in
PMTCT and HAART programmes. Results: Until recently, PMTCT programme
faced various difficulties, which resulted in high rates of lost patients. Because of
fear of stigma and discrimination or due to social and economical constraints
some women were not able to follow the rules required by PMTCT protocol. Some
of them escaped from the protocol and delivered in maternity wards where no
PMTCT programmes were taking place. On another side, HAART patients had a
good observance. Interviews pointed out the positive impact of HAART on the
patients’ physical and psychological welfare as well on their social integration.
Since the implementation of HAART activities in the hospital, including
Information Education Communication activities on availability of AIDS treatment
in the area, PMTCT activities have improved. Women are more willing to receive
counselling, to be tested and to be involved in PMTCT protocol. Conclusions: The
availability of HAART programme improves the implementation of PMTCT
activities in our research area in India. Our presentation will show more precisely
the social and psychological impact of HAART provision for women engaged in
PMTCT

Poster. HIV PMTCT In Home Delivery Care In South India: An Anthropological

approach. HIV Congress 2006. 10-12 March. Mumbay. India

Objective: Today, there is a common assessment that broadly 15% of HIV

infected pregnant women involved in HIV Prevention of Mother to Child
Transmission (PMTCT) protocol escape at the time of delivery. They give birth at
home with Traditional Birth Attendants (TBAs). In some part of India, women of
remote rural areas also deliver at home with TBAs, without any PMTCT care, as
such programs are only available in few health care services. In such context it
is highly relevant to explore the possibility to provide HIV PMTCT care during
home delivery. Methods: This paper presents results of a research Project « HIV
Transmission amongst birthing practices in Southern India, anthropological
approach » which aim was to study delivery practices in various system of birth
(from biomedical to traditional setting) in the context of HIV/Aids. Results: The
study of birthing practices in rural areas points out the lack of awareness of TBAs
as well as rural women on HIV/AIDS. It also shows TBAs practices that may
increase (such as late cut of the cord) or decrease (such as the absence of
artificial rupture of membrane) the HIV MTCT. Conclusions: Women delivering at
home should also benefit of HIV PMTCT. Prevention should then be adapted to
local contexts and cultures to reach as many women as possible. Relevant
activities can be done in order to provide HIV PMTCT in home delivery care.

2005

Demedicalization of HIV PMTCT in South India:The opportunity of theTransfert of

knowledge to Traditional Birth Attendants. 5th International AIDS INDIA
Conference-OCTOBER 20-23rd, 2005. Chennai, India

In Southern India, programs of Prevention of Mother to Child Transmission of

HIV ( HIV MTCT) have been started in some governmental hospitals and by some
NGOs but it exist neither in private clinics nor in rural areas where deliveries are
conducted at home by the so called “Traditional Birth Attendants” (TBAs). In
PMTCT programs itself, there is a high loss of follow up of patients who got
tested and were attended antenatal consultations but who don't coming back to
deliver at the hospital. In such context, the distance that separates HIV MTCT
recommendations of International Health Organizations from the actual delivery
practices at home may be viewed as an extremely fertile field of study of the
diverse social factors which condition the actual implementation of the envisaged
safeguards. The question to train the TBAs, first to reduce the maternal
mortality, then to play an active role in the prevention of HIV transmission is one
of the debates in the international Health Organizations. In one side, the « for
TBAs » are fully convinced on the benefit to train them. In an other side, the
« against TBAs » wish to fight for the complete disappearance of their practices.
In this framework, we can explore the social role and position of TBAs as well as
the determining factors of their abilities, knowledge and social capacities to apply
preventive measures during delivery. The objective of the paper is to describe
the complexity of the question to know if the TBAs have to be or not to be
involved in the implementation of HIV PMTCT programs in South India.

Birth Practices Today. The Popular Representation of the Rise of Caesarean

Section In India Healing Today Soundings in the contemporary fashions of Indian
medicines International Seminar. 28.10.2005. French Institute Pondicherry.

In India, Sushruta considered in Ayurveda history as the father of surgery

already performed Caesarean section in IV century. Since the end of XX century,
C. Section was mainly a surgical procedure implemented to insure the security of
woman and child. Today, in India as in many countries, Caesarean has also
become very popular and is sometimes done without medical needs.
Determinants of change in obstetrical practices with favour to C. Section are
concerned with various logics coming from medical side as well as from patient
side. I will focus on the latest and explore how the logic of the star and logic of
the body drive people to the demand of C. Section. In opposition to this, social
constraints (mostly) shape also resistance to C. Section practice. Finally popular
representation of the rise of C. Section will be described in the whole context of
social change in India shaped by what Reynolds called, the “technocratic
imperative”.

2004
Enjeux des formations des matrones en Inde. Aspects sanitaires, sociaux et
politiques et portrait ethnographique. Séminaire Histoire, anthropologie,
démographie de la petite enfance EHESS Paris le 19 novembre 2004

Les données présentées ont été recueillies dans le cadre du projet de recherche
« Transmission du VIH et pratiques d’accouchement en Inde du sud, approche
anthropologique » initié par Centre de Recherche Cultures, Santé, L’objectif
général de ce projet est d’éclairer la façon dont les facteurs sociaux et culturels
relatifs à la conception, la grossesse et l’accouchement, au sein d’un contexte
donné, accroissent ou non la vulnérabilité de l’enfant à naître à l’infection par le
VIH. J'ai choisi de vous parler des matrones parce qu'en tant qu'institution
sociale elles représentent un prisme à l'étude des représentations et pratiques
autour de la naissance. Dans un premier temps de cet exposé, je présenterai les
enjeux des formations des matrones en Inde. Dans un deuxième temps nous
nous intéresserons au cas particulier de Satchadie une matrone de Pondichéry et
aux transformations contemporaines de ses savoirs et pratiques. L'objectif de
cette présentation est de montrer comment des approches théoriques diverses
de l'anthropologie de la reproduction permettent de mettre en évidence certaines
logiques culturelles, sociales et politiques, individuelles et collectives, en œuvre
lors de l'événement de la naissance.

HIV Transmission and Delivery Care in South India: Theoretical approach and
practical issues. SSR-WISER seminar Risks and realities of HIV-AIDS in
everyday lives: Ethnographic insights and implications for Policy. October
6th & 7th 2004, Amsterdam

In Southern India, HIV MTCT programs have been started in some governmental
hospitals and by some NGOs but it exist neither in private clinics nor in rural
areas where deliveries are conducted at home by the so called “Traditional birth
Attendants”. In such context, the distance that separates HIV MTCT
recommendations of International Health Organizations from the actual delivery
practices at home may be viewed as an extremely fertile field of study of the
diverse social factors which condition the actual implementation of the envisaged
safeguards.
This paper presents the main preliminary results of a research Project “HIV
Transmission amongst birthing practices in Southern India, anthropological
approach”. The specific objectives are to: 1) set up an ethnography of child-birth
practices for studying the underlying causes of HIV MTCT 2) analyze the
variations in the practices in various systems of birth (traditional, semi traditional
and biomedical) 3) evaluate the applicability of the preventive measures
recommended to health care providers as well as to TBAs. I will consider the
question of MTCT from the point of view of public health and then suggest
research perspectives in four fold approach of anthropology of reproduction
presented by the problematic of MTCT and HIV: “socio-cultural”, “medical”,
“social change” and “political” approach. In using the frame given by the four
fold approach, I will present the problematic of HIV PMTCT from the perspective
of the Home Delivery Practices of TBAs.
The “cultural approach” will focus on the representations, role and limitation of
training of TBAs, the “medical approach” will be illustrated by two examples of
birth practices of TBAs, the “social change” approach will show how the concept
of authoritative knowledge in obstetric is relevant to study the discourse and
practices around TBAs. Then, the “political approach” will point out how HIV
PMTCT ARVs procedures can be seen as an example of social categorisation of
patients. Meanwhile I will describe the constraints of women and TBAs to deal
with ARVs at home. Finally we hope to show how the four fold approach of
anthropology of reproduction is relevant to study HIV MTCT and home delivery
care in South India. At the end, some recommendations will be given on the
training of TBAs and their eventual role in HIV PMTCT in communities.

Notes on the sanitary, social and political stakes of Traditional Birth Attendant’s
training in India International Workshop Mirrored Views on Healing Systems in
India : Merging Policies, Politics and Practices, 19th and 20th of April 2004,
French Institute of Pondicherry. India.

My current research is principally related to study of reproduction in Tamil Nadu

One of the objective is to understand the role of different health practitioners in
traditional, semi-traditional and ‘contemporary/western’ medical settings. In that
context, and particularly in rural areas it is highly relevant to study holy sphere
in witch the practices of the traditional birth attendant are taking place. The
objective of this presentation is to describe and analyse how the TBAs are in the
middle of political stake’s debates on representations on modernity and tradition.
The recording of the various social movements around TBAs training
demonstrate how those relations are built with and by the distribution of power.
It shows how the authoritative knowledge is produced, distributed and fight in
the sanitary, social, and politic interactions.

Naître dans une communauté d’Intouchables en Inde du Sud. Cycle de

conférences. Exposition « Naissances, objets, rituels ». Musée de l’Homme. Paris.
4 Février 2004

Aujourd'hui en Inde, malgré le développement d'infrastructures sanitaires, une

majorité de femmes accouchent toujours à domicile, en particulier en zones
rurales. C’est le cas de Karik, un village du Tamil Nadu, en Inde du Sud, abritant
une communauté d’intouchables, où les femmes ont recours aux matrones pour
les soins de l’accouchement. Dans un premier temps, j’aborderais le contexte de
la procréation d’un enfant en Inde. Ensuite je présenterais différents aspects des
pratiques d’une matrone lors de l’accouchement : le déroulement du travail
d’accouchement, la gestion de l’accouchement compliqué et les variations de
pratiques autour du cordon. L’objectif de cette présentation est de décrire le sens
donné à l’événement de la naissance en milieu dit « traditionnel » et les
contextes sociaux, économiques et politiques dans lequel il s’inscrit.