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Bull World Health Organ vol.86 n.4 Genebra Apr. 2008
Mexico's midwives enter the mainstream
Training traditional midwives to work alongside doctors offers the best of both worlds to women giving birth in Mexico, writes Theresa Braine.
Sidelined during the 20th century in Mexico and other parts of Latin America, midwives are making a comeback. The new prevailing wisdom is to combine the efforts of doctors and traditional midwives in hospitals and clinics. The idea is to keep the use of modern delivery, such as stirrups and caesareans, to a minimum.
"Around the world the midwife's role is diverse and evolving," says Hedwig van Asten, a technical adviser for the Making Pregnancy Safer department at the World Health Organization (WHO). "A midwife's responsibilities can vary depending on the setting, and can range from health promotion to emergency life-saving measures," she tells the Bulletin. "It's a universal word that does not have a universal understanding. However, what is clear is that midwives can meet the clinical and cultural needs of mothers and newborns."
Within that context is a range of expertise and levels of training. While midwives are commonly deployed in Europe, in the Americas they went out of fashion in the latter part of the 20th century apart from in some rural areas of Latin America, including Mexico, where "traditional" midwives continued to practise and deliver the majority of babies.
In recent years, a new breed of midwife in Mexico has emerged with the establishment of the Centro para los Adolescentes de San Miguel de Allende (CASA) school in San Miguel de Allende that offers a three-year degree plus one-year residency in professional midwifery. CASA, established in 1981, is Mexico's first government-accredited midwifery school. Now several nongovernmental organizations are also developing and running programmes that offer professional midwifery degrees.
In a further development, Mexico's health ministry has started encouraging doctors to work closely together with traditional midwives. The department of Medicina Tradicional y Desarrollo Intercultural (Traditional Medicine and Intercultural Development) was established at the ministry of health in 2002. It is in charge of the national midwifery programme, which is designed to provide culturally appropriate care to Mexico's indigenous people with their preference for mobility during childbearing as opposed to lying down with feet in stirrups.
"We are a society with many points of view," says Dr Hernán Jose García Ramirez, deputy director of CASA.
About 250 000 babies are born in Mexico annually, according to Dr Alejandro Almaguer, director of CASA. In the poorest states of Chiapas and Oaxaca, 60% of births are attended by traditional midwives with little or no professional training. In the rest of the country, 1% of births are attended by a midwife as opposed to a doctor. A total of 35 000 midwives are registered in Mexico, Almaguer says.
While CASA trains midwives and sends them into the countryside to improve their skills during school vacations, the health ministry takes a different approach bringing traditional midwives into formal medical settings to work with doctors.
Both the CASA and health ministry approaches seek to reach pregnant women through an avenue they trust the community pillar that is the traditional midwife. Both see cooperation between midwives and doctors as essential for reducing maternal mortality.
Besides making care more professional and evidence-based while reducing the need for surgical intervention, the community approach gives postpartum care too. In some cases, women can stay for three days in a hostel attached to the hospital after giving birth, García says. Traditional midwives give massages both during labour and postpartum, and during labour the woman can give birth in a squatting position.
García cites examples of where the health ministry approach is working. In the San Luis Potosí state municipality of Aquimon, there were 11 cases of maternal death in 2004, he says. In most cases, either the midwife identified a problem, but couldn't get the woman to the hospital quickly enough, or treatment was inadequate. In both instances, the midwife got blamed, he says, so the resultant drop in trust made midwives simply stay home with their charges.
In 2004, however, doctors and midwives in that municipality made a pact of sorts. Midwives agreed to attend births using hygienic practices and learn to identify risks and complications, while doctors agreed to treat midwives with respect and allow women to give birth in the position they choose. In 2005, there was only one maternal death, García says, that of a pregnant woman who was beaten to death. It has yet to be seen how the relatively new approach affects overall maternal mortality in Mexico.
"This new co-delivery approach offers the best of both worlds," García says, adding that it represents a shift away from a predominantly medical approach to birth. Midwives trained by CASA recall how, to gain the trust of the communities where they worked, they had to explain the difference between traditional and professional midwives and debunk a common myth that midwives are witches.
Two federal laws have helped to reinstate the importance of traditional midwifery. In 2001, a constitutional reform was passed giving the country's indigenous population the right to preserve their culture and traditional medicine. In 2006, a law was passed requiring the Mexican government to respect traditional knowledge. Laws have also been passed recently in states, such as Veracruz, which give women the right to a life free of "obstetric violence", such as unnecessary caesareans, García says.
Both García and CASA co-founder Nadia Goodman believe it is still hard for "professionally trained" midwives to gain acceptance because nobody knows what that means. According to García, there's even some disagreement within the health ministry over the best way to deliver babies. He points out that textbook training doesn't benefit all midwives, since those in rural areas do not always read or speak Spanish. There may be about 2000 registered midwives in each of Mexico's 31 states, but there are an unknown number who are active but are not registered.
Training traditional midwives, García says, is "building on what already exists it's what Mexico needs more than professional midwives."