Text and Photos: Carlos Eduardo Gómez
As 2015 draws to a close, so does the period set for 189 United Nations member states to meet the eight human development goals agreed upon fifteen years ago. The hardest goals to achieve in Latin America have been eradication of extreme poverty and hunger, universal primary education, and reduced maternal death rates.
Why has it been so difficult for Latin America to meet the goal of reducing maternal mortality? The situation in Colombia and Paraguay has remained static, while Ecuador showed exemplary progress toward all the other goals except this one.
Why is this scourge so persistent and how can it be eradicated? Although Guatemala and Perú likewise failed to meet the goal, their experiences could help other countries in the Americas set up health programs and further progress toward this goal.
The Situation in Guatemala
This colorful and multi-ethnic country has a population of some sixteen million, six and a half million of whom are indigenous peoples, so it is not surprising that 48.3% of births are assisted by midwives.
This is why Lourdes Xitumul —National Minister of Women’s Issues― considers it a great achievement to have obtained approval for a national intercultural health policy, thanks to support from the Ministry of Health, midwives’ associations, civil society, and the United Nations Population Fund (UNFPA). She explains: “After holding thirty-three discussion sessions (in the twenty-four languages, including Spanish, spoken in the country) in the twenty-nine health districts of the twenty-two departments, we were able to recognize and disseminate the ancestral wisdom possessed by midwives.” Midwives were encouraged to interface with the health system, institutional care of mothers and newborns was improved, and the work of midwives as agents of change was strengthened. In this respect, Lourdes notes: “These tools made it possible to close the gap and bring about a balanced approach, to recognize other forms of knowledge, reduce mortality rates, ensure safe, clean births, and consolidate a system serving the health of Guatemalan women.”
To learn more about the work of a midwife, I join Sabrina Morales, a Population Fund official in the department of Chimaltenango, where 48% of the population lives in rural areas. There we meet Mrs. Naty, a midwife who is a member of Tierra Viva, an autonomous organization of women working to defend sexual and reproductive rights and build a culture free of racism, sexism, and violence. She feels that midwives are born, not made, and that they receive the gift of their skill in a dream. She began studying to serve from a very young age.
She offers to let us accompany her on a home visit. Once there, Mrs. Naty proffers affectionate greetings and asks after the seven children she has already helped bring into this family. She introduces me to Paola, who wears a lovely hand-woven striped blue skirt. She is twenty-one and expecting her second child. Mrs. Naty checks her weight and asks about any problems and her diet; she massages the expectant mother’s stomach and prescribes a tea of local herbs. Paola sees Mrs. Naty because she trusts her and she believes that a hospital will not stimulate the baby or try to position it like the midwife does with massages; she is also afraid the hospital would perform a Cesarean. If a problem emerges during the pregnancy, Mrs. Naty will refer Paola to a doctor for an ultrasound, and depending on the results, the young mother may still be able to have a home birth. Most midwives recognize that the hospital system also has a role to play.
The following day, we travel to San Juan de Comalapa. At the Community Health Services Association (ASECSA) ―an NGO that has been working at the primary level of community health for more than thirty-eight years― we meet Maya leader Magdalena Cholotio, who feels that multi-culturalism should go beyond mere recognition to achieve genuine interaction between two or more cultures. It means accepting that indigenous peoples have their own cosmovisions and particular ways of understanding reality. “For us, health transcends an anthropocentric vision. Health is life in full and life in harmony with our surroundings, with the earth, the water, and the cosmos. We treat the socio-cultural illnesses of our peoples, such as indigestion, sunken fontanel, the evil eye, fright, etc. We also treat the ordinary illnesses of people of all ages and cultures.”
When we visited, a group of twenty-five midwives from several communities was receiving training and sharing experiences. Most of the women they serve give birth sitting or squatting, with the help of husbands or grandmothers. The midwives also know effective family planning techniques. Some doctors in the western health system understand that midwives are a valuable resource, and one doctor’s clinic even has a temazcal, or steam bath, used in traditional indigenous medicine for hot massages after birth. After finishing the course, the midwives receive a certificate and a bag containing materials to ensure clean, safe births in their communities.
I have the chance to talk to Rosa María Chex, a 59-year-old midwife who has brought over a thousand children into the world during her twenty-three years of service to the community. She studied herbal medicine for five years and her garden provides everything she needs to practice her profession. “The midwife ‘finds’ pregnant women and provides help. A midwife gives her life and her time; a doctor follows a schedule. At a hospital, a woman has her baby and goes home the next day. We do not just assist with births: we support the women and we guide and advise them throughout the pregnancy. We deliver the child and we visit it every day during the forty-day rest period, continuing for up to two years. This is why people refer to us as ‘grandmothers.'”
Mrs. Rosa meets with Dr. José Florencio Simón ―gynecologist, obstetrician, and director of the health center― for a patient’s pre-natal check. The doctor says that midwives continue to play a significant role in assisting at births in Guatemala. “I myself was born with a midwife in attendance. Here in Comalapa we have a pretty good relationship and we try to integrate different types of wisdom. In other communities, especially where there are many midwives and a weak health system, there is a certain resistance to institutions. The community associates going to a health center with ending up in an operating room, so women prefer to give birth at home with the temazcal. Some colleagues recognize the work of midwives and are sympathetic to them, while others think the practice is backward and should disappear.”
This health center adapted one delivery room for births in an upright position, but according to Mrs. Rosa, it has never been used. “We are caught between the center director and his staff. Sometimes the director understands and lets us accompany women to the check-ups and gives us advice, like now, but when a different director or nurse arrives, we have to start all over again.”
It is certainly true that there is no competition. While the hospital has three doctors who take turns seeing patients and attending births for a population of 42,000 inhabitants, there are sixty-five full-time midwives in town. “We have a network; we meet here at the health center once a month to report patient numbers and their condition and we study and share experiences. Every year we renew the license that identifies us as trained midwives,” concludes Mrs. Rosa.
The Situation in Perú
Continuing with my research, I headed to Ayacucho (Perú), where the UNFPA regional office has been supporting women’s and state organizations in combining traditional and modern knowledge and designing an intercultural health policy. I am accompanied by Dr. Gracia Subiría, who notes that “Perú is one of the first countries in the region to have a complete protocol of intercultural adaptation for births in an upright position. Health personnel have been trained in interculturality, and indigenous communities have been educated on their sexual and reproductive rights. Governments have promised the United Nations that they will guarantee suitable health services to indigenous peoples and that these communities will be given equal attention that is culturally appropriate. This commitment has improved maternal health and saved lives. Social programs operate in concert and the budget has been substantially increased; in addition, a Ministry of Culture with a Deputy Minister of Interculturality has been created.”
According to Clelia Rivera, leader of the Ayacucho Women’s Federation, pregnant women who visited the health centers for check-ups in the past did not return, so any complications during delivery resulted in death. Health centers never recognized their own mistakes in terms of poor treatment and negligence.
“That is why we made an effort to improve organization: we continuously monitored the women’s health, we followed up on deaths in childbirth, and we documented everything, so we were able to provide proof when we presented our case,” states Clelia emphatically. “To give you a simple example: when a woman went into labor, she was told to take off her clothes, but for an indigenous or rural woman, it is not easy to get undressed in front of strangers. Then the woman was put on a stretcher, with her legs spread so anyone passing by could see everything. To boot, she was scolded in Spanish, a language she spoke poorly or not at all; she was not allowed to walk around (which lessens the pain); and she could not drink her maté beverage. Health personnel do not understand their customs or their philosophy of life.”
Even if women lived near a health center and went there for check-ups, it is not difficult to see why they preferred to give birth with their trusted midwives in a warm room in the company of their families. “So we sought the help of the Population Fund and other organizations in reaching agreements,” explains Clelia, “and we succeeded in introducing the upright birthing position and honoring their need for privacy and support, thus providing respectful service to indigenous and rural communities.”
Ayacucho regional health director Dr. Ilianov Fernández points out that the Ministry of Health has tried to understand and blend ancestral and modern knowledge: “We designed a plan to improve the health system for mothers and children, and today 60% of women have access to medical examinations and a care plan; some health centers attend 93% of births in a upright position and there are Quechua-speaking personnel. These factors have made it possible to repair the social fabric and regain the trust of women, so that now 90% of births take place in institutions.”
To see this in action, we traveled to the health center in Vilcashuamán, seventy-three miles from Ayacucho at an altitude of 10,555 feet. A notice on the door reads: “You decide your birthing position.” We are welcomed by obstetrician Marlene Saira, who has assisted at more than seven hundred upright births in ten years on the job. “I was not taught this technique at school, and it was a shock when the protocol for culturally-appropriate births came out, but I gradually began to understood and undergo training. Everything is easier in an upright position: the infant does not suffer; it is faster, safer, less painful, and more humane. The mother can be accompanied by others who help with the birth, like her husband, her mother, or a midwife. Starting from the first appointment, the women know they can choose how they give birth and that they can bring and drink controlled amounts of their maté.” I visit a new delivery room: it is equipped for many types of birth, with ropes to grab while standing, a stool, and a modified stretcher. The room has a heater and is painted and decorated in pastel colors. Everything stands in readiness for the expectant mother.
The midwives of yesterday are today’s community health agents: they seek out expectant mothers, explain the benefits of the health system, guide them, counsel them, and refer them to a medical center or hospital.
At the Maternity House attached to the hospital, I meet a young couple who walked five hours to get there. They will stay here for a month. They left their farm and their animals in the care of a mother-in-law and a brother. A full meal plan in a restaurant will be provided by the Ministry of Health on weekdays, while the residents cook together on weekends. Plants for steeping maté grow in the garden. I talk to Florinda, who has been staying at the Maternity House for fifteen days. While her husband washes clothes and hangs them out to dry, she drinks a maté to warm up. “When I had my first child six years ago, they did not ask me about anything. Now it is different and I plan to give birth squatting, just like my grandmother did.”
Later I speak with several couples, who all agree that they feel much more comfortable and have been treated better. They are also happy that some of the nurses caring for them speak Quechua. Now they have the time and trust to tell their stories. Intercultural dialogue has proven to be the right way, a way that saves lives.