Midwives, givers of life in rural communities, in danger of disappearing

“The problem is not that they demand certification,” explains Oñate, “but all of the pretexts involved and the struggle for power, between medical knowledge and the knowledge of the communities.”

Nahua interpreter and homemaker Irma Martínez complains that doctors, assistants, and administrative personnel in clinics, health centers, and hospitals threaten and disrespect midwives and their patients because of their status as indigenous people. Their attitude amounts to discrediting an ancestral practice.

Martínez explains that in her community, Piltepeco, midwives are recognized by physicians in the region, a recent development.  In November 2013, a preliminary hearing of the Permanent Peoples’ Tribunal took place in the community of Acatepec, Hidalgo, where midwives explained the importance of their work and the difficulties they face, such as limited support and scarcity of materials needed to provide their service.  The meeting with the judges and the community provided the opportunity to explain that in no way are they against hospital personnel, and that all they ask for is support, respect, recognition and the preservation of the traditions and customs that define them as a people.

“More women have died in the hospital than with the midwives”

Nahua midwifery in the more than 20 communities that make up the municipalities of Yahualica, Xochitiapan and Huautla, in the state of Hidalgo, is an ancestral practice and community health service passed down from generation to generation.  Having a midwife in the community has always been  invaluable due to her extensive knowledge and the mysticism of the ritual, which involves being present not only during the pregnancy, but also during birth and the postpartum period.

Currently there are few midwives in the communities, in part because the health system intimidates them and seeks to eradicate the ancestral custom. Health officials frequently denounce the Nahua midwives, and many women choose not to enter the profession of their grandmothers and mothers.  This is why their legacy, the passing down of knowledge and preservation of their culture and customs, are in danger, Martínez points out. She has been a companion and interpreter for about 25 Hidalgo midwives, in addition to dedicating herself to her home.

The practice of the midwives is not a job or an option. Martínez explains that it has a divine origin in dreams. That is where the midwives are told how to attend to the birth, the importance of hand- washing the clothes of the mother and the baby; they are shown how to cut the umbilical cord and which herbs they must give to pregnant women.  It is a recurring dream and is a sign that they must adopt the profession, and if the women don’t follow it, they become ill to the point that they may find themselves on the brink of death.

Accepting the gift implies a very strong commitment and sexual abstinence, even if they are married, in which case they become “sisters” to their husbands, the researcher Oñate explains. 

“We cannot leave our patients alone, at any time we go to them,” testified one of the women at the Peoples’ Tribunal.

Martínez, as the “voice of the midwives”, narrates the experience of one of the women. “She dreamed that the Virgin told her that she had to be a midwife, how she should attend to the baby and the patient.  She did not accept being a midwife. On various occasions she dreamt of the Virgin, and soon she fell ill and she could no longer get up.  She lost her appetite.” Due to her numerous illnesses, the midwife’s parents had to find a healer to treat her so that she could exercise the profession, because if she didn’t, she would die.

Midwives possess vast knowledge in the treatment of pregnant women.  They are experts in medicinal plants and can help move the baby if it is in a position that could put it at risk.  They pray for the mother and the new being that is about to be born, since they believe that God is the one who does the work and they simply help. They also know how to receive the newborn and how to bring him or her closer to the mother.  “That is why our work is valuable,” they stated at the Peoples’ Tribunal.

Doctors are not aware of these details, says Martínez, but they insist on telling the pregnant women not to go to the midwives because it is risky.  However, she notes that “more women have died in the hospital than with the midwives.”

Their work, cultivating individuals who will respect the community

When a woman discovers she’s pregnant, she or her family invite the midwife to take part.  “Starting at that moment, she (the midwife) is rooted in the community because she has to look after the woman full-time and attend to her in her language,” says Teresa Oñate.

When the baby is born, various rites are performed that have to do with weaving together community, details Oñate.  For example, the umbilical cord is buried along with a banana plant.  After one year, the plant should be producing and the child will distribute its fruits, as a symbol of joy for his or her survival and to share the fruit of their flesh. 

“That way they won’t be stingy and learn to share with others,” explains Oñate, who studies a postgraduate in Rural Development.  “And reciprocity is one of the fundamental pillars of life in the community.”

“They have to bury part of my body so that I will give fruit, just like corn,” a woman explained to Oñate so that she would understand why the midwives bury the placenta of the newborn child.

At the moment of burying the placenta, which is considered a part of the child and sacred, the midwife gives one of her names to the baby. 

“We don’t just bury it any which way, first we ask God, we light a candle and we give Mother Earth liquor to drink and a little tobacco, and the smoke of copal incense. That way we ask that the child grows as it should,” said one of the Nahua midwives at the audience. 

They perform these rituals in the child’s home. “That’s so they’ll know where they grew up and where their placenta is buried, and most of all they will know where they belong,” she explained.  “That is rooting, and it is sacred, being well-planted in the community,” indicates Oñate.  “If this is lost, values are lost as well.”

The midwife doesn’t just receive the baby. She cooks, she teaches the art of being a mother and washes their clothes for two weeks.  The period is closed with a ritual bath for the mother and child. “It is a community party that is like a presentation.  The nude boy is bathed over a girl, or vice versa, the chosen people become godparents and we all eat and share the joy of the newborn.  Everyone joins together and becomes family.  The children of the community are everyone’s, and everyone’s eyes will watch over them,” she says.

“They are guardians of rules and values, and if you attack them, you put this whole system at risk,” says Oñate.

Criminalization of traditional midwives

Nahua midwives in the Huasteca communities of Santa Teresa, Crisolco, Zacayahual, Chompetetla, Tenamaxtepec, Zoquitipan, Texoloc, Acatipa, Acaetepec and Axtitla, among others, report that government health programs impose a form of reproduction that attacks their culture and traditions, and deceitfully deprives families of their own forms of reproductive self-determination.  These official practices have effectively criminalized midwifery and placed obstacles in the path of the midwives. Many have been forced to adopt practices that go their training and convictions.

These practices were imposed in the context of compliance with the so-called Millenium Goals– objectives agreed on by the United Nations in the year 2000, which will be revised in 2015.  Among these objectives is the reduction of maternal mortality, which has not been achieved in Mexico, notes Teresa Oñate.

“Maternal mortality is multifactorial.  Women don’t die in childbirth due to being attended to by a midwife. On the contrary, the World Health Organization recommends using midwives and taking advantage of their knowledge, rather than stripping them of their duties. Here there’s been a misunderstanding, unfortunately,” explains Oñate.

To practice legally, Mexican midwives must now be certified through a program included in the General Health Law that seeks to improve their medical abilities. But the budget to support them with transportation or food for the days of the course is insufficient.  Teresa Oñate notes that these women live in remote communities with little transportation. Many have to walk for hours to get to where doctors give the certification courses, and sometimes they don’t have anything to eat. 

“On one occasion, they took one of them to an event in Pachuca (the capital city of Hidalgo), where they gave her a beautiful set of equipment for her work and took pictures.  The surprise was that at the end of the event, they picked up the little briefcase and she never saw that equipment again,” adds Oñate.

Even those who obtain certification are prohibited from using herbs and massaging the women, and even attending births. They have to send the woman in labor to the closest hospital or clinic, under threat of incarceration if “something” were to happen to the patient.  Once in the clinic, midwives are prevented from accompanying the woman, “since they see them as barefoot, indigenous grandmothers, without respecting the fact that they are the ones who know the mother best and have years of experience,” states Oñate.  If the midwife does attend to the woman, they deny or slow down the birth certificates to pressure families to be seen in the clinics in the future.

Doctors, meanwhile, tend to use the service of midwives when it’s convenient for them, since they significantly reduce the cost of having medical personnel in the communities. But at other times they insult them and scold them as if they were children, says Oñate. The researcher lives in the Huasteca region and has seen firsthand how medical personnel fail to take into account that the local midwive have attended to dozens of births, while the doctors many times have attended to few or none.

Institutions likewise take advantage, trying to force midwives to undertake tasks that are different from those marked by their gift, such as keeping a registry of pregnancies, going into peoples’ homes to promote contraceptives, which goes against the custom that they must always be invited by the family to initiate their work, and convincing women to be sterilized.

The results of these difficulties and threats can already be seen.  In communities close to Huejutla, one of the most important cities of the Huasteca region in Hidalgo, there are no midwives anymore, Oñate reports. “They say it’s too hard” she says and yet they suffer and even get sick for not being able to exercise the gift that was given to them.  

Another reason for the decline in midwives services is the steep decline in the number of children born, to the point that in some communities, such as Piltepeco, the schools that were built after long citizen demands are at risk of being closed down. Oñate believes that there is a specific government  interest in depopulating the region that could be related to implementing extractive projects.

For the families, measures to force pregnant women to be attended to in official clinics have serious repercussions.  From being a joy, the birth of a baby becomes a burden due to the costs of travel and hospitalization. 

“Birth, which had been in the sphere of self-sufficiency, is being pulled into the market,” says Oñate.  The costs also mean that the family cannot offer the communal food for the presentation of the child, and they lose a ritual that is vital in connecting him or her with the community, she adds.

Being treated in the clinic also significantly raises the chance of Caesarian, many, according to Oñate’s investigations unnecessary. This means the family “loses” the woman, mother, wife, and worker for up to a year, because “for them it is a surgery from which one must recover for quite some time since they do lots of heavy work.”

The elimination of rites designed so that the newborn will respect the earth and the community, and everyone will consider her part of their family has a tremendous impact in terms of the loss of the sense of community. “In the communities there is already a division between children born with midwives and who were sown in the earth, ‘the ones who respect,’ and the ‘clinic children’ that the people believe do not do have the same connextion,” adds Oñate.

“And there are other things that we can’t yet see, such as what will happen to all of those children born in clinics outside of their community.  Their birth certificate doesn’t say that they are from their community, and for the land program, that catalog indigenous communities, that might be a problem,” says Oñate.

“Spaces and elements that are fundamental to the reproduction of this world view are being altered,” summarizes the researcher.

Two rounds of violence: discrimination and criminalization

Faced with the growing criminalization of midwifery in the communities of Hidalgo, Simón Hernández, lawer at the Miguel Agustín Pro Juárez Human Rights Center, says ancestral wisdom is at risk in a situation of serious  persecution by the state. This violates rights in two ways: through discrimination against indigenous practices and criminalization of a profession that is fully recognized by Mexican legislation.

Many women dedicated to this profession have been threatened and harassed in the last few years by health offices in Hidalgo, in spite of the existence of national and international instruments that recognize the rights of indigenous peoples to free self-determination and autonomy.

The principal legal instruments that protect rights regarding indigenous health and the right to preserve their customs are International Labor Organization Convention Number 169, the Universal Declaration of Human Rights, and Articles 2 and 4 of the Mexican Constitution.

“The predicament in the communities of Hidalgo illustrates a violent relationship with the government, which does not recognize the forms of organization and health administration of the people.  And when they discriminate, they generate a criminalization of everything that the State considers that they should or should not do, which affects their subsistence and far from benefitting the relationship with indigenous groups, it makes it worse, since the normative system believes it to be uncivilized or aberrant,” Hernandez states.

In Hidalgo has a state bLaw of Indigenous Rights and Culture, which states in Article 13 that indigenous peoples have the right to maintain their health practices with their own traditional medicines and the training, updating, and certification of traditional doctors.

Hernandez notes that the problem is that the practices of the people need to go through the validation by the State. 

“An example of this is that the midwives have to be incorporated into the health system, and to do that they have to have a formal recognition so that they can work, so there is always this historical discrimination in terms of how they recognize this knowledge, and this should not exist.”

“There is always a relationship where society in general belittles indigenous society, because while here we have physicians, the communities have midwives or healers, and whereas we have normative systems, they have practices and customs,” says Hernández.  The State has been obligated to recognize these rights, the core of the struggle of indigenous people in the twentieth century, however, the relationship of equality is still a pending topic, he states.

A dialogue between equals

The researcher Teresa Oñate says that the struggle of the midwives is to have their work recognized as a cultural institution.  “Pregnancy, birth, and postpartum have to be considered ethno-medical events, not just a question of health. They are medical events that are interwoven with world visions that you can’t write off, because people will die on you,” she says.

She says that this implies recognizing other dimensions of knowledge, and midwifery as part of an indigenous medical system.  The midwives are happy to be certified, since they want to improve their knowledge and highly value being able to recognize signs of complication like preeclampsia and having alternatives, like clinics or hospitals, for these cases, affirms Oñate, who accompanies the practitioners.  But above all, they demand respect for their work.

The WHO recommends having a dialogue between the medical knowledge of both systems but with full equality. 

“There must be conditions so that when midwives recognize that they cannot attend to a woman due to complications, she can be given other attention.  They need helicopters, closer clinics, decentralization of the second and third levels of the medical system, an effective communication system with them, and above all that they can choose whether or not to refer their patients,” says Oñate. Doctors should also undergo training and become more sensitive, she adds.

Above all, a reevaluation of the work of a midwife is necessary “Those who should evaluate and certify them are the communities,” states the researcher.  “The Health System must at the very least support them with transportation, or come give training in centrally-located communities.”

By tradition, midwives cannot receive a salary or payment, but they can receive support through, for example, the cornfields of the communities. 

“But everything has to come from below, from the communities.  It can’t come from above because we already know that it will come across all twisted. (The support) is always insufficient and doesn’t make it to where it needs to go,” Oñate concludes.

Adahazira Chavez is a journalist and managing director of Desinformemonos.org, where this article was originally published in Spanish.

Translation: Lindsey Hoeman/CIP Americas Program