Autonomous midwives and the methodology of this investigation
The argument presented in this chapter is based primarily upon extensive fieldwork that I carried out during the years 2014 and 2015.1 had also conducted initial interviews in 2013 (Laako 2015, 2016). 1 interviewed 15 midwives in depth in the Mexican states of Mexico City Federal District, Chiapas, Oaxaca and Quintana Roo. The midwives who participated in this research constitute a representative national sample. The interviewed midwives themselves estimate that there are 20-50 “autonomous” midwives in all of Mexico. Although the autonomous midwifery movement is a small one, it is influential because of its participation in larger networks.
According to the report of Comité Promotor por una Maternidad Segura en México (the Mexican Committee for Safe Motherhood, 2014), of the 104,379 healthcare providers engaged in sexual and reproductive healthcare in the country, only 78 are officially registered midwives who attend births. This figure does not include traditional midwives, who number about 15,000 according to the previously cited report. The caregivers who attend births in Mexico include professional midwives, nurse-midwives, general practitioners and obstetricians/gynecologists. However, only midwives devote 100% of their time to this particular work. As mentioned in the introduction to this book, there are four midwifery schools in Mexico: the CASA School for Professional Midwives in Guanajuato, the Escuela de Mujeres Aliadas in Michoacan, the Escuela de Partería in Guerrero and the Escuela de Iniciación a la Partería Luna Llena in Oaxaca. In addition, nursing and obstetric careers are offered by the National School of Nursing and Midwifery (see for example Carrillo 1999; Page 2002; Araya 2011; Argiiello and Mateo 2014; Sánchez 2015).
The midwifery centers visited for this research included Luna Maya, Nueve Lunas, Madreluz, Osa Mayor and TICIME. At the time of their interviews, around half of the interviewed midwives were members of the Mexican Midwifery Association (Asociación Mexicana de Partería (AMP)), which was established in 2012. Others have not been members and do not seek to become members at this time. Still others had been active members, but have resigned for the time being. At the time of this research, the AMP had just emerged as one of the principal organizing and networking forums for those midwives who sought professional autonomy, certification and regulation in Mexico. Yet, in this mission, the activities and efforts of the AMP also generated heated debates and struggles of different kinds. My research was related to AMP but not reduced to it nor was it the principal focus.
One of the main objectives of my in-depth interviews with the midwives was to explore how they decided to become midwives, and why. Also ofinterest were how they tell the story of midwifery, and what they believe is at stake with midwifery in Mexico today. The interviews also explored aspects of the agendas of these different midwives: what unites them or makes them different from each other, but also what kind of midwives there are in Mexico, and how these middle-class or urban-origin midwives are related to traditional midwives. In addition to the interviews, I carried out participant observation in April 2015 during the First Regional Congress of the AMP, in the state of Quintana Roo. At that Congress, a questionnaire was completed by 15 midwives—mostly traditional Mayan midwives from Quintana Roo, but also some from the state of Chiapas. These midwives’ responses made possible an initial comparison among different types of midwives.
In addition to the interviews and questionnaire, my research is based upon a triangulation of various materials: websites, brochures, reports, articles, videos and social media sites in which the midwives’ debates and discussions took place.
It is important to note that the midwives interviewed and discussed here are of the type that I have defined as autonomous as a result of this research. By “autonomous midwives,” I refer to politically active midwives who mainly have a middle-class, urban profile, who are critical of the official medical system (i.e. anti-systemic), and therefore prefer to practice their profession outside the institutional environment. Several of them, however, since becoming midwives had relocated in rural areas, where they also adopted different lifestyles with the pursuit of getting closer to the Mexican rural, traditional and Indigenous roots as well as pursuing environmental sustainability. Most of the interviewed midwives were Mexican, but foreigners with permanent residence were also included.
Thus, my focus was with those midwives who identified themselves as autonomous or engaged with this notion in multiple ways during my research. They have also been active in establishing midwifery centers, associations and networks in their pursuit of strengthening “autonomous” midwifery in the country.
The concept of autonomy was a necessary point of departure of this research because these midwives called or labeled themselves as “autonomous.” By using that term, they seemed to indicate a critical societal stance that was importantly tied to the reemergence of a particular type of midwifery activism in the country, and which also set them apart from the categories of professional and traditional midwives. Thus, I started with the objective of exploring who these “autonomous” midwives were, given the previously explained complicated context of Mexican midwiferies (see Introduction and Chapter 1). During my research, the concept of autonomy was deepened and extended, and was continually emphasized by this particular set of midwives to describe the kind of midwives they felt they were.
As noted in the introduction to this book, the International Confederation of Midwives and other major international organizations define a “midwife” as one who has graduated from a government-recognized program, as indicated by the adjective “professional” (International Confederation of
She breaks paradigms and leaves a trail 69 Midwives, 2011a). In practical terms, that definition excludes the majority of midwives in a country like Mexico. To be sure, some midwives of my study had credentials from abroad while others had been trained via apprenticeship with other Mexican midwives. Thus, most fall outside the official international definition and its scope.
The definition of the traditional midwife is even more problematic. Internationally, a traditional or empirical midwife is coded as a “traditional birth attendant” (TBA), as she lacks the government-recognized certification required of a professional midwife. However, these midwives constitute what is still probably the majority of midwives in the world, especially in rural and poor regions. In general, and as is often the case with artisanal professions, these midwives have learned their profession in a way that is hereditary and (as the term implies) empirical, via experiential learning during their apprenticeships; their mentors are often older family members such as mothers, aunts and grandmothers. Some say they learn in dreams or from God (Araya 2011; Arguello and Mateo 2014); others simply learn by doing, without any teachers at all. In the Mexican context, it is often thought that traditional midwives are those who identify themselves as Indigenous; however, this perception can be misleading. Although many Indigenous midwives do define themselves as parteras tradicionales, this category is very broad and complex due to several simultaneous processes. For example, in Veracruz many midwives have recently certified as “traditional.”2 This certification, above all, allows those midwives to detect possible risks and they are usually encouraged to deliver women to hospitals. However, the certification also seeks to bring traditional midwives within the state legislation in attending pregnant women and homebirths to reduce maternal mortality.
Yet this example is only one among many, and the situation of midwifery certification is complex and murky in Mexico. To better understand the contemporary legal context and its problems in terms of midwifery in Mexico, I recommend consulting the introduction to this book as well as López et al. (2019). Here I have mentioned the example of Veracruz to show how ambiguous the categories of different midwives are in Mexico, with ever more complex legal implications. For example, according to my interview results, many of the registered “traditional” midwives in Veracruz have not been Indigenous but rather semi-urban mestizas.3 Indeed, some autonomous midwives interviewed chose to seek certification as traditional midwives, despite being urban, middle-class and highly educated. They seek this certification because it is the only one available to them—there is no national certification for professional direct-entry midwives.
Another sector of midwives are the licenciadas en enfermería y obstetricia (LEOs), nurse-midwives who graduate from four-year university-based programs, and tend to practice in hospitals and to be more inclined toward nursing than midwifery.
Indigenous midwives do not form a homogeneous group either, as they include both “traditional” midwives and trained midwives who incline towardthe biomedical system, thus ceasing to correspond to the common image of traditional/lndigenous midwives. Some midwives have referred to themselves as “hybrid midwives” (parteras híbridas), as they are a mixture of the traditional and the professional-biomedical.4
Finally, a sector of midwives includes the technical midwives (parteras técnicas), who graduate from one of the government-recognized midwifery schools in Mexico. Most of these midwives work in hospitals and clinics; many, like the LEOs, exercise a more nurse-oriented role (Carrillo 1999; Davis-Floyd 2001: Seymour 2010; Sánchez 2015). Some are part of today’s wider midwifery movement in Mexico, which intends to establish more midwifery schools in the country, and to achieve certification and better positioning of midwives within the healthcare system.
I emphasize that, although the essential objective of this chapter is to understand the particular activism of autonomous midwives—as will be shown below—this collective action in its broader sense also includes other actors, such as feminist groups, perinatal educators and doulas.5
Midwifery in Mexico today is conditioned by different contexts: rural, urban, economic, regional, class and ethnic. Each midwife, depending upon her location and context, is subject to policies that condition her work. At the same time, she positions herself in particular ways to confront policies that tend to impede her work. Therefore, the researcher needs to maintain a critical distance from the essentialist definitions of different midwives as “frozen in time.” Only by doing so can the researcher locate the definitions of midwives in a shifting, politicized, debated field, which is recognized by the midwives themselves as a disputed terrain. Indeed, the imagery of “the midwife” has played an important role globally and historically in the midwifery battles and counter-battles. Thus, I emphasize that, while my use of the term “autonomous midwife” seeks to identify and highlight a particular type of midwifery activism and reemergence of midwives in Mexico since the 1990s, it is not a strict, closed definition, but rather an instrumental and illustrative one, which has its own shortcomings as a result of the complexity of the context. However, it does incite us to rethink political activism, autonomy and human rights in contemporary midwifery.