Towards the end of the 20th century, midwives were sidelined across Mexico and parts of Latin America. With a public health system that pushed women to give birth in hospitals came the stigma around midwifery, and the perception that it had no place in modern medicine. Today, 96% of deliveries in Mexico are attended by doctors in hospitals.
But while maternal mortality has fallen – in 2015, 890 women died due to pregnancy, half as many as in 2000 – it remains significantly higher than the OECD average.
The national figure also conceals vast disparities and inequalities. In 2012, the risk of dying during pregnancy was five times higher for women in the country’s poorest 100 municipalities, and three times higher for indigenous women.
"All over the world, women who are indigenous are at the bottom of the barrow"
"In terms of gender inequality, all over the world, women who are indigenous are at the bottom of the barrow. They have the lowest education, the highest maternal mortality rates, the highest rates of being survivors of violence,” said Nadine Goodman, founder of the CASA midwifery school.
Poorer and indigenous women are more likely to give birth without the right assistance: in the states of Chiapas and Oaxaca, the majority of births are not attended by any trained professional. Almost all of these deaths are preventable, if the right care is in place.
“No woman should have to die needlessly related to pregnancy and birth,” said Goodman.
Data: The World Bank
A re-recognition of tradition
The solution is not to be found in simply getting these women to hospitals, doctors, and surgeons.
Many indigenous women fear or dislike hospitals – often unaffordable and unfriendly places where they are not allowed to be accompanied by friends or family. Medics may dismiss their traditions, discriminate, and not speak their languages. Some indigenous women do not want to be made to give birth in beds, preferring instead to squat or take an upright position.
"Women are not treated as the protagonists of their own pregnancies"
“Everyday in Mexico, 4,500 women give birth in public facilities, and almost 100% don’t have the right to have a family member or friend accompany them - why? Scientific evidence shows accompaniment means less painful labour,” said Goodman.
Mexico’s hospitals lack the resources to provide high-quality care to so many thousands of mothers. Swollen demand has resulted in mistreatment and even violence towards mothers and babies, and to excessive medicalisation of delivery. Mexico has the fourth highest rate of C-sections in the world, with numbers rising year on year.
“Women are not treated as the protagonists of their own pregnancies,” said Goodman.
So, rather than simply sending more women to hospitals and doctors, NGOs - and now even health officials - are increasingly turning back to the long-rejected midwives, professionalising and training a new generation.
Globally, more than 800 women die every day from preventable causes related to pregnancy and childbirth, practically entirely in developing countries. But more than four in five maternal deaths could be averted with proper midwifery care.
"The UNFPA, the WHO - they are recommending professional midwives: they give true choice and lower maternal mortality rates. The power of their care is proven as the vanguard," said Goodman.
"Ancient knowledge is evidence-based knowledge - not witchcraft"
The CASA midwifery school
The organisation responsible for much of this change in “prevailing wisdom” is CASA, based in Guanajuato in central Mexico. CASA opened the first government-accredited professional midwifery school in the late 1990s. The school grants a professional license and legal backing to work as an autonomous professional midwife anywhere in the country.
“Before, there was no option to include traditional knowledge alongside up-to-date allopathic treatments in studying midwifery. The point is to have both perspectives, a plurality of forms of medicine to get the job done. Ancient knowledge is evidence-based knowledge - not witchcraft,” said Goodman.
CASA offers a three-year degree followed by a one-year residency that includes spending weeks at a time working and living in the countryside. The idea is to bring together traditional practices, from massages to a preference for squatting, with modern developments.
"Indigenous women have the lowest education, the highest maternal mortality rates, the highest rates of being survivors of violence"
“We have specialist neonatal physicians and traditional midwives on our teaching team - both are valuable. It’s not an either/or situation - that’s what’s so exciting: you can learn from the ancestors,” said Goodman.
The school recruits mainly rural women and has targeted outreach for attracting indigenous students, giving preference to women who are related to traditional midwives. “The program is open to traditional midwives with at least nine years of education, or to someone who is, say, a granddaughter of traditional midwife,” said Goodman.
Students and staff have attended more than 8,000 births, with better clinical results than state and national averages, from reduced infant mortality to lower caesarean rates.
“We’ve had outside evaluations from the National Institute of Public Health of Mexico and internal data shows that at CASA clinics the C-section rate is consistently lower than 15%. Mortality and morbidity rates for mothers are lower than state and national levels, low birth weight data is superior to state and national data, and 99.9% of women choose to be accompanied.”
The future is in the government's hands
While CASA is small, the school has had a major impact on the advance of professional midwifery in the country.
There are now CASA-supported midwifery schools authorised by state governments across the country. “We’ve helped in a number of different states to open programs - Guerrero, Potosí, Morelos, Oaxaca,” said Goodman. The model has even spread to Guatemala, where a midwifery school has now graduated its first cohort of students.
"We have a long way to go to practice what we preach”
Thanks in part to CASA’s advocacy, the federal government is also starting to join the midwife movement. A Department of Traditional Medicine and Intercultural Development has been established in the Ministry of Health and in 2006 a new law passed that requires the government to respect traditional knowledge. The Ministry has also begun to bring traditional midwives into formal, medical settings to work with doctors.
A critical moment for CASA took place in 2011, when the federal government finally added midwifery to its official list of health care professionals, formally bringing them into the public health system and funding eight states to hire midwives to serve indigenous communities.
“This was really important. Anything an NGO does should be in collaboration with government, and your litmus test of success is if there is structural change that permits all this to happen without you,” said Goodman.
Since this development, public sector jobs are now open to CASA graduates, and more than 40 have been employed by the government. "But we really need public universities and schools if we’re going to produce many more midwives without sacrificing quality of education,” said Goodman.
There has been some success on this front. In 2012, the first public midwifery school opened in Guerrero, the state with highest maternal mortality rate and almost a fifth of the population being indigenous. The school is modelled after CASA’s curriculum and has had CASA graduates providing technical and teaching support. The Universidad National Autónoma de México has also launched a new nursing and obstetrics program.
Still, there is much more to be done
“The government has made a positive shift in the last two years, but we have a long way to go to practice what we preach,” said Goodman. “They have no plan to really assess how many professional midwives Mexico needs or how many low-risk births should be attended to by midwives rather than the physicians."
"The role of an NGO is to try politically risky, innovative projects, and to demonstrate with statistics that they work. It's government that has to scale up”
CASA cannot reach Mexico's mothers in need alone. Training midwives, with tuition, room and board, costs $250-$300 a month per student, funded mainly by foundations.
“The international bodies say every country should have six professional midwives to attend 1,000 women of reproductive age. A professional midwife can handle 175 births a year. Mexico has 2.5 million pregnancies a year. They need a ton of midwives, but they don't want to invest the money,” said Goodman.
Between 100-200 professionals have now graduated from CASA’s original school. But Mexico would need 2,700 qualified midwives to attend just one in five annual births. It would need many more than that if it hopes to achieve the same success as countries with institutionalised midwifery, such as Peru and Chile, where 60%-70% of births are attended by a midwife.
To truly have a situation in which mothers have quality choice for their health care, much more needs to be done.
"The role of an NGO is to try politically risky, innovative projects, and to demonstrate with statistics that they work. It's government that has to scale up,” said Goodman.
(Picture credit: Flickr/Ken Bosmer)
Odette Chalaby
odette.chalaby@apolitical.co
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