海角大神

The pangs were quickening when Nancy Salazar Lopez arrived at a hospital in the remote city of Huajuapan de Leon in Oaxaca one recent Sunday. She felt her baby was coming.

But doctors did a cursory check and said she wasn鈥檛 ready. They asked her to return in a few hours. She did, again and again. They kept turning her away, the last time after her water had already broken and blood dribbled down her legs.

鈥淭hey said there weren鈥檛 enough doctors,鈥� says Salazar鈥檚 mother, Jesus Ofelia Lopez Cisneros, a 47-year-old ethnic Mazatec, one of 15 major indigenous groups that live in the southern Mexican state.

Her daughter gave birth that evening on the hospital鈥檚 concrete steps, unable to gain entry. As the birth took place, a crowd gathered. The father swaddled the newborn in a cloth. A physician emerged after more than five minutes.

鈥淭hey were shouting at him. They said he was an idiot, that he should help her,鈥� Ms. Lopez says. The physician asked for forceps to clip the umbilical cord. A second doctor emerged and helped lift the mother onto a gurney.

The birth of Salazar鈥檚 child Jan. 26 on the periphery of the main state hospital here is far from unusual. Seven times since mid-2013, women have given birth on the lawns or steps of hospitals or health clinics in the states of Oaxaca and Puebla. The cases are known largely because bystanders snapped photos or took videos, and later posted images on the Internet.

The cases almost always involve darker-skinned women 鈥� mostly indigenous, as Mexico鈥檚 native groups are known 鈥� and they鈥檝e laid bare the discrimination that some patients say underlies Mexico鈥檚 health care system. A cardboard sign taped to the wall outside the General Hospital here says, 鈥淓nough of racism!鈥� But the cases also expose shortcomings in policies that have swamped hospitals with routine pregnancies that could be cared for in health clinics or even at home with the help of midwives.

Spooked by the national publicity given to the cases in Oaxaca, the third poorest of Mexico鈥檚 31 states, state Health Secretary German Tenorio Vasconcelos has said that he鈥檚 fired four physicians and suspended two in cases where pregnant women have been denied entry to clinics or hospitals.

He cited a 鈥渕ixture of carelessness and medical inexperience鈥� and said he鈥檇 uphold a 鈥渮ero tolerance鈥� policy to ensure that doctors attended to all pregnant women in a timely fashion.

Independent experts on maternal care scoff at such assertions, saying that punishing doctors is the easy way out for health officials who don鈥檛 want to confront the broader problems of an overburdened system they helped create.

鈥淚鈥檝e said it to the secretary鈥檚 face: He is looking for scapegoats. These measures are totally oriented to the media,鈥� said Paola Sesia, a U.S.-educated medical anthropologist who works at the Oaxaca branch of the Center for Research and Advanced Studies in Social Anthropology.

After being turned away three times over a period of seven hours, a pregnant 16-year-old gave birth last week in a car outside the clinic in Salina Cruz, a Oaxacan port. The physician in charge was immediately suspended.

The case of another young Mazatec woman raced across the Internet in early October. When Irma Lopez Aurelio went to a state health clinic in the town of Jalapa de Diaz, personnel wouldn鈥檛 admit her, saying no doctor was available.

Photos later showed a grimacing Ms. Lopez, wearing a maroon print dress, dropped on one knee, with her newborn son, Sabino, on the grass on clinic grounds.

Lopez鈥檚 husband, Margarito Andres Velazquez, later complained of how long it took state health officials to acknowledge that they鈥檇 mistreated his wife, and that happened only after a team from one of Latin America鈥檚 largest television networks showed up.

鈥淭he cameras from Univision arrived before the secretary鈥� of health, he told reporters.

Cameras in cellphones have, indeed, highlighted the treatment of indigenous women at hospitals across Mexico, bringing to light conditions that were barely noticed before.

Maria del Carmen Oseguera, 21, gave birth on the waiting room floor of a women鈥檚 hospital in Tehuacan, in Puebla state, on Sept. 7.

It took more than a month before a witness in the room uploaded a video of the scene to YouTube. In the video, one can hear Ms. Oseguera鈥檚 husband, Ricardo Tehuintle Baez, complaining to hospital personnel. A receptionist responds: 鈥淭here are few of us for so many people.鈥� The husband is then heard saying, 鈥淏ut I came here yesterday!鈥�

The quasi-official human rights defender in Oaxaca state, Arturo Peimbert Calvo, said of such videos, 鈥淭echnology has turned into an ally in providing testimony of violations of human rights.鈥�

While some activists chalk up such cases to racial discrimination, other experts say that more complex factors come into play, including attitudes of superiority by medical personnel toward poorer patients, especially women who speak an indigenous language.

鈥淭he women arrive and say, 鈥業鈥檓 about to give birth.鈥� They say, 鈥楴o, you鈥檙e not ready yet,鈥� 鈥� says Maria Cristina Galante of Nueve Lunas, a nonprofit advocacy group for maternal health in the Oaxacan capital.

鈥淭he doctors speak to them in medical terms 鈥� 鈥榊our cervix isn鈥檛 fully dilated鈥� 鈥� and the women don鈥檛 understand,鈥� says Ana Maria Hernandez, a women鈥檚 rights activist and the head of the nonprofit Consortium for Parliamentary Dialogue and Fairness in Oaxaca.

The state has seen dramatic changes in the way maternal health care is provided over the past three decades. In the 1980s, more than half of births took place at home, usually in rural areas, attended by midwives.

After a 1983 constitutional amendment gave every Mexican the legal right to health care, state governments began to react. By the early 2000s, eager to reduce maternal mortality rates that were nearly double the national average, Oaxaca mandated that all pregnant women should give birth in health clinics or hospitals.

Since then, clinics and hospitals have been flooded with pregnant women, without a corresponding increase in personnel.

At rural clinics, sometimes only a newly graduated physician completing mandatory public service is on call, and wary of mishandling patients.

鈥淭hey are all afraid of the repercussions because if there is a maternal death, it鈥檚 on their hands,鈥� Ms. Galante says.

So they often send women on to the state鈥檚 40 or so hospitals 鈥� either under state or federal administration 鈥� where doctors, if swamped, may take advantage of a quota that allows them to say cesareans are needed and pass them along to private hospitals, where many doctors also work on their off hours.

When pregnant women are referred to the private hospitals, the state reimburses doctors the equivalent of $1,750 for the caesarean, an incentive.

鈥淎lmost no one talks about this because it touches on the mafia that surrounds health policy,鈥� Galante says.

Still, many pregnant women find themselves pacing outside hospitals or sitting in waiting rooms, waiting for admission.

Angel Sanchez, a 27-year-old day laborer whose wife gave birth on the hospital steps in this city, says there were about three other pregnant women waiting for spots ahead of his wife when 鈥渟he suddenly said, 鈥業 can鈥檛 take it anymore.鈥� 鈥�

Mr. Sanchez says medical personnel had told all the women to pace the sidewalk to speed contractions.

鈥淭here are many women suffering outside because they don鈥檛 want to see them inside,鈥� Sanchez says.