The two meandering paths in contemporary perspective: The emergence of autonomous midwives

Beyond its undoubted social value, motherhood represents a deadly risk for many women ... The WHO [World Health Organization] considers maternal mortality to be an indicator of insufficient coverage and quality of maternal and reproductive health services in the country, and research indicates that the vast majority of the causes of these deaths are closely related with the socio-economic conditions of the population. Hence the high percentages of maternal mortality in women speaking Indigenous languages in five states: Oaxaca, Guerrero, Chihuahua,

Yucatan and Chiapas ... Many women prefer to give birth at home for the simple reason that they want to have a humanized birth. What does that mean? Basically it means having proper health conditions, as well as emotional ones. Professional care in a humanized birth implies, among other things, that the person who delivers the baby puts the needs of the mother first. This represents a radical change from the traditional gynecological approach ... Thus, it is clear that it is important for traditional midwives to become professional. The Center for Adolescents of San Miguel de Allende (CASA) is a community-based organization in Guanajuato that opened its doors in 1996 and has the only government-accredited professional midwifery school. It aims to expand the model of professional midwifery to reduce maternal mortality, to eliminate unnecessary C-sections [cesarean sections], and to improve the process of pregnancy so that the newborns weigh more and arrive in better condition. Its goal is that in every rural community in Mexico there will be a professional midwife to accompany the birth process in an effective and humanized way.

Dr. Marta Lamas 10/06/2012

An excerpt from an article “Maternal mortality and humanized birth’’ in the Mexican newspaper Proceso 1858 (pp. 56-57, author’s translation) (Lamas 2012)

When talking about maternal mortality related to the medical practice of traditional Indigenous midwifery, it is crucial to define what you mean by traditional midwives and which group of practitioners you are referring to, and, further, what are the technical considerations that support the promotion to a professional or humanized birth, as you indistinctly call them ... The developments in research on maternal mortality in the country are limited to only one part of classical epidemiology: the statistics. While these are extremely important, when used alone they are reductionist and incomplete. Maternal mortality must be addressed in its multiple bio-socio-anthropological determinations in order to avoid falling into “mere interventions” in the training of traditional Indigenous midwives, since the only thing being accomplished here is a medical ethnocide, by leaving Indigenous communities without an alternative care that has not even been investigated by bio-social scientists, and by turning traditional Indigenous midwives into nurses, at best.

Dr. Rafael Lavin (OM1ECH advisor) 02/07/2012 An excerpt from the response to Lamas in the Mexican newspaper Proceso 1861 (p. 81, author’s translation) (Lamas 2012)

The considerations that lead me to support CASA’s work are the following: their Professional Midwifery School works to prepare

Underdogs, turf wars and revivals 51 competent midwives with a mixture of ancestral Indigenous knowledge and current gynecological-obstetrical knowledge. This blend of tradition and modernity has made midwife graduates well received in rural communities, while at the same time, as the studies are incorporated within the Guanajuato Secretary of Education, they are paid well by the government. I support CASA because its pedagogical model recovers many Indigenous practices that you mention, and because the multidisciplinary nature of the teaching team seems appropriate, ranging from certified professional midwives to traditional midwives, from doctors specialized in ob-gyn to anthropologists and psychologists. In addition, every semester the students spend two to four weeks visiting different states of the Republic to do fieldwork, with traditional midwives as teachers.

Dr. Marta Lamas 02/07/2012

An excerpt from the response to Lavin in the Mexican newspaper Proceso 1861 (p. 81, author’s translation) (Lamas 2012)

Mrs. Lamas also says that the pedagogical model of the school “recovers many Indigenous practices”. Perhaps it is so; however, in their long presentation to us, CASA never mentioned any. Instead, at the end of their visit, the heads of CASA expressed very clearly what could be achieved, according to them, in terms of traditional midwives. They said that for the traditional midwives, it would be puny [canijo] to be recognized by the government and that given this, the best thing to do is to open a training school for their daughters or granddaughters (authorized by the government) so that they could work in peace and also receive a salary from the government. ... They declare that there are only 23,000 midwives left in the country for a universe of more than 100,000 communities, and that is why CASA was created. However, despite all the private and governmental support they have received and used for the development of their model, as they told us, in their 13 years of existence, they have graduated only 60 students. At this rate, it would take something like five thousand years to barely reach the number of traditional midwives that exist in the country today, and 20 thousand years, double the current human history, to achieve [CASA’s] goal of providing universal coverage of a professional midwife in every community of the country. Would it not be more sincere, more fraternal, or at least more realistic, to propose to fight for the 23,000 midwives who already live, and with them their own system, which also happens to be the one on which the cultural bases of our Mexico are born?

Sebastiana Hernandez Intzin (President of OMIECH) and Micaela Ico (trained in traditional Indigenous medicine) 15/07/2012 An excerpt from the response to Lamas in the Mexican newspaper Proceso 1863 (p. 96, author’s translation) (Lamas 2012)

I apologize for not having been sufficiently precise in my article and having led to a misunderstanding. 1 hope that my slip has not become a source of conflict, because I consider it very important to [maintain in the forefront] the concern that you and CASA share for the future of midwifery and for women’s sexual and reproductive health. 1 understand, as you have already made clear, that there are different perspectives to address midwifery. In our country, with such a diversity of Indigenous and traditional cultures, there are also different perspectives on midwifery; its transmission to other generations; and [its] economic self-reliance. Not all midwives give importance to the same objectives, and precisely because there are so many difficulties surrounding the exercise and future of midwifery, it seems to me that dialogue between different views can be helpful.

Dr. Marta Lamas 15/07/2012 Excerpt from the response to Hernandez et al. in the Mexican newspaper Proceso 1863 (p. 96, author’s translation) (Lamas 2012)

Attempts to bring back professional midwifery in Mexico have increased since the 1990s. As shown by the important discussion above, which also underlines the subtle tensions between contemporary midwiferies in Mexico, these attempts continue to be linked to the destiny of traditional/Indigenous midwifery in the country. Thus, the two meandering paths of professional and traditional/Indigenous midwiferies continue in the 21st century, now accompanied by the revival of what could be called postmodern or autonomous midwifery, together with shifting rights and policies related to midwifery work.

According to Karina Felitti (2009), fertility politics related to the demographic explosion in Latin America in the 1960s are strongly linked to current family-planning politics, which in the 1990s, again, were particularly linked to the emerging human rights discourse. Thus, a tension exists between governmental public policies on sexual and reproductive health and the respect for privacy, intimacy and autonomy of every person to decide for themselves about their sexuality and reproduction—a key element of the current reproductive rights frame. The former has often generated obstacles for the latter (Felitti 2009, 57).

These tensions can be perceived, for example, in the evolution of contraceptive methods in Latin America since the 1960s. In addition to bringing societal changes and economic development that transformed the position of women in Latin American societies (especially of women in urban and highly educated classes), the evolution of contraceptive methods was tied to demographic control. Although family planning has become more related to human rights than to geopolitics and demography (as previously noted), it still forms part of the historical context of these policies in Mexico (Felitti 2009).

In the late 1980s, the emergence of the concept of sexual and reproductive rights positioned women more as principal subjects and agents of these policies, supported by the Latin American feminist movements (Felitti 2009). Since the 1990s, these frames have been particularly linked to the problem of maternal mortality. It is noteworthy that, although international policies now emphasize access to health services as a way to reduce maternal mortality, Mexican research has shown that about 70% of Mexican mothers who die as a result of childbirth do so in hospital facilities, and not at the hands of traditional midwives (Freyermuth 2013, 2015; G1RE 2013; Sesia 2013). Nevertheless, the same international policies had serious consequences for traditional midwives, who were displaced from maternal care with the justification of the high rate of maternal mortality, which was easy to blame on them.

The consequences for midwifery are varied. As will be discussed in Chapter 5, the focus of international policies on maternal mortality increased the institutionalization of birth and threatened the work of many trad-itional/Indigenous midwives. On the other hand, the human rights discourse, which later gave birth to the Latin American concepts of obstetric violence and humanization of birth, helped autonomous or professional midwives to re-launch in Mexico (see Chapter 2). Simultaneously, Indigenous rights movements emerged forcefully in Latin America during the 1990s. Thanks to that emergence, Indigenous doctors and midwives could, at least potentially, argue for their own healthcare system in the frame of Indigenous rights and reproductive justice.

These developments have also given rise to “intercultural health” as a concept during the past decade, although this concept is still far from being a reality (Sesia 2013). Interculturality is an increasing field of academic study in both Latin America and Mexico, and is mainly tied to education, although medical and health system fields are emerging. It is also noteworthy that, in Mexico, there is a strong distinction made between multiculturality and interculturality. Multiculturality as “sensitivity” is understood as a notion driven by the dominant society’s attempts to reconcile guilt while maintaining the same societal stratifications. Interculturality, again, is understood as a concept that underlines equality and true integration of Indigenous cultures into society while maintaining their rights to their own culture and medicine.

Yet maternal mortality has been the principal issue to promote professional midwifery and/or the modern professionalization of midwifery in Mexico (Freyermuth 2015). Indeed, as indicated in the discussion at the beginning of this section, CASA—one of the first schools for training and certifying professional midwives—was created in 1996 to reduce maternal mortality. According to Mills and Davis-Floyd (2009), another objective of CASA was to carry forward the knowledges of the aging traditional midwives with whom the CASA students are required to conduct internships. Other venues for professional midwifery training have since come into existence, such as the midwifery school in Guerrero, which is based on the CASA model, and Mujeres

Aliadas in Michoacan. Both also aim to diminish maternal mortality, especially among the Indigenous populations.

Again, Mexico’s autonomous/postmodern midwives, who will be discussed further in Chapter 2, mainly emphasize another set of women’s rights linked to social movements and societal criticism. They tend to have well-educated, urban, middle-class backgrounds but they also lean toward the roots of midwifery and the Mexican traditional/Indigenous traditions. These autonomous midwives emerged in the 1990s, first with the creation of Part eras TICIME in Mexico City and Tepoztlan, Morelos, and thereafter created many other regional associations.

In “La partera profesionak. Articulating identity and cultural space for a new kind of midwife in Mexico,” Davis-Floyd (2001) explains that the first autonomous, non-traditional midwife to practice in Mexico was Patricia Kay, an American homebirth midwife licensed in New Mexico with ties to CASA. She and her husband ran the TICIME clinic in Tepoztlan for over 10 years, where Patricia attended births either in the clinic or at home. According to Davis-Floyd (2001), Patricia helped to create two streams of autonomous midwifery in Mexico:

  • 1. She conducted a professional three-year training for a small group of formerly traditional midwives, including Antonia Cordova, who later professionally trained four other formerly traditional midwives. They became the first midwifery staff at the CASA Hospital in San Miguel and Antonia became its first Clinical Director, teaching the CASA students clinical skills for many years.
  • 2. Patricia also conducted a three-year professional midwifery training program for a group of urban, middle- and upper-class women in Mexico City (Davis-Floyd 2001), some of whom later traveled to Texas to obtain further training and practice experience at the autonomous border clinics in El Paso such as Maternidad La Luz.

One of these original autonomous midwives trained by Patricia is Laura Cao Romero, the founder of Parteras TICIME in Mexico City. Laura is one of the pioneers of postmodern/autonomous midwifery in contemporary Mexico.

When I interviewed her in 2015, she told me about her history within Mexican and global midwifery:

I had a so-called natural birth myself, but in the hospital, a long time ago. However, I thought that the hospitalized births were attended very mechanically. So little by little I found out about other things, especially the book Parto renacido [Birth Reborn] by Michel Odent. It was influential. It opened for me the alternative option to attend births that I had been looking for but hadn’t found. Later, I traveled to London and Vienna and found out about homebirths, and started to reconsider that option. In Mexico, in the 1950s and 1960s, they had closed all the midwifery

Underdogs, turf wars and revivals 55 schools and replaced all the parteras tituladasfyust as Ana Maria Carrillo writes in her articles. So, luckily enough, I met Patricia in Tepotzlan. She was like a model of the professional, autonomous midwife. We started to think about a group and a program, about what to do with professional midwives in Mexico in a more independent way. Many of us had carried out our practice in the US, especially in the maternity schools in El Paso, Texas. Obviously, it is important to note that while we were in this particular struggle, the traditional midwives had not been forbidden, although their work was reduced to mere participant-observant. I refer to those hospitals that claimed to be bicultural and invited midwives, but it was more about the task to take care of patients during postpartum and in the birthing room, they were mere bystanders. Their positioning in Mexico has not been easy, either, although they preserved a little margin in which to exercise their profession.

Laura considers that, in the late 1980s and early 1990s, a kind of initial search for new paths was carried out in Mexico by midwives of two types: those who had previously been certified, but subsequently replaced, and new ones who sought to become professional midwives. According to Laura, this search had to do with globalization, in the sense that new information and consciousness about different options for birthing were arriving in Mexico.

Yes, thereabouts between 1980 and 1987 we were at least three midwives who tried to establish birth centers more independently. We didn’t want to be nurses, because that is not midwifery, and we didn’t want to be dependent on the doctors either. There was also an excess of medical obstetrics, and it just seemed impossible that the midwife could emerge from there—their organizational heads even told me so in 1994. So we basically had to create our own space elsewhere. And so globalization arrived, the information and consciousness about how to attend births in other countries ... We informed ourselves. We had also been part of the waves of feminism in the 1970s, especially against violence. I suppose that is where what Robbie Davis-Floyd has called the “postmodern midwife” was born; which is in the crossroads of all this, between the biomedical and the traditional that was born in the context of activisms. We have asked a lot about how to promote midwifery in Mexico, how to promote humanized birth, and which model of midwifery would be ideal for Mexico. We need autonomy, but also a model of midwifery different to Holland, Chile or France ... I mean, our own system, and a system that would favor the autonomy of the woman—she has to be in the center of the mission. We have to collaborate so that each woman can decide what the best is for her, and not to impose, because sometimes this also exists in both systems. I mean, the natural birth sometimes also has these characteristics of imposition and so we have to be also self-critical.... But the challenge of self-regulation in midwifery in Mexico, it is important,

but has to do with the variety of techniques: what will be our techniques of evaluation of midwives within the multiple models of midwifery in the country without being too exclusive? Especially when the midwives tend to have strong personalities, and many of them have formed their own models to do things. There are many who do what they do or can do in their contexts, and they are very difficult to judge from the outside. They also resist co-option, because this is fundamentally an autonomous profession for them.

Indeed, Laura also acknowledges the existence of a division between traditional and professional midwiferies in the country, as different models. Nevertheless, she also points out that midwifery, as an apprenticeship-based profession, has always involved sharing of knowledges:

The thing is that traditional midwifery ... they tend to be the wise women of their communities, I mean, it is the community that creates their midwives but also sets the conditions for collaboration. It is another kind of midwifery, in this sense. It is the relationship that the midwife has with her community, it is from there that she emerges and performs her role. Now there is a rupture, a change in these traditional models because currently the government employs coercion by which it takes away the autonomy of the traditional midwife. This has to do with the high rates of maternal mortality, especially in rural areas, the use of C-sections, the fear of complaints, all these things in Mexico that are simultaneously under the watchful international eye to reduce these rates. So, in the rural areas they obligate the midwives to take their women to clinics to birth, to avoid maternal mortality. I cannot say that this system promotes humanized birth ... Now there are also many midwives, who are young Indigenous and they are more allopathic than we!

Laura also highlights that, in her experience, collaboration with traditional midwives, especially Indigenous midwives, always had to do with an exchange of practices, not training of Indigenous midwives:

This is the way that midwifery has always been. It is in its nature. You learn by sharing knowledges because midwifery is based on apprenticeship. A great deal of midwifery is based on conversation between midwives; the way in which we casually share about the profession. So in this sense, I don’t believe in training but sharing. ... Indeed, in the beginning, perhaps during the first half of my life as a midwife, I concentrated on creating networks between traditional midwives and other countries. We published a bulletin called Conversando entre Parteras [Conversations among Midwives] during ten years, which also served this purpose. These networks consisted of different midwifery conventions in the US, Spain, Brazil and Canada. We made exchanges. I also carried out research on the

Underdogs, turf wars and revivals 57 linguistic exchange between midwives and doctors in different geographical locations. [I also] made a video showing the different techniques of massage to show in an anthropological conference and to spread these practices. In my case, I never had the impression that they [traditional, Indigenous midwives] would feel that I stole their knowledges. They saw me as their equal. They would say: “Despite the fact that you are from the capital, you attend [births] like us.” In this bulletin, which I am thinking of writing in [the form of] little books some day, we published testimonies from traditional midwives, doctors, mothers and fathers, also from historians writing about ancient Mexico. I [make this known], I suppose, because I think we managed to create a small but interesting network that worked like a window to the foreign midwifery world, about the worth of midwifery and Indigenous medicine in our country. I think this also differentiated us from the “brood” of professional midwives of the 19th century and mid 20th century. We didn’t want to distinguish ourselves or to discriminate against the traditional midwives. Afterwards, we sort of disappeared as a civil association because we didn’t have the funds any more and we dedicated ourselves to attending births, so we couldn’t continue this work of constructing bridges of understanding, as we were more focused on attending the birthing women.

However, Laura feels that currently the times are more favorable to midwifery in Mexico than in past decades:

I see more force now in all the levels. The women seek more midwives now. It is possible that now there are more options, as well. Globalization also helps in this way. However, what we lack is that the birthing women mobilize more themselves. We need the women to mobilize against obstetric violence and for the humanization of birth. ... Yes, traditionally it has been the middle-class women who seek midwives because they have more resources and access to globalized criticism of birth. You also have to remember that there were maternity lodges before, which is not a new invention. There have always existed different models in which women have given birth. Yet, in our experience, there are more and more lower-class women also seeking us now; the [globalized criticism of birth] is arriving there, too. There are more and more women who seek a different kind of care, and more force in all levels to drive the midwifery work. It is, at the end of the day, a women’s movement, not just of midwives.

Laura ends by making reference to the recent developments related to the perspective of human rights in childbirth:

Let’s see, we in the Parteras TICIME, like many other midwives in Mexico, we have formed part of midwifery politics at the international level for a long time, especially in the congresses of MANA. It is fromthese collaborations that were born, at the time, the CASA [1996] and the midwifery school in Guerrero, which has been in existence now for five years [as of 2015]. Also the doula movement is part of all this, for humanized birth. In 2007, we also established the Parto Libre A.C., which had on its agenda, among other things, human rights in birth. This process took place after the first Congress of Humanized Birth, carried out in Brazil in 1985, and afterwards also in Brazil in 2000. So it is there that we made visible the indiscriminate use of technology in births. From there onwards, the Network for the Humanization of Birth [ReHuNa] was established and has existed now for 15 years. It is a group of people to humanize [birth]. Brazil has really been the node of this mobilization.

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