[Article originally published as part of the Childbirth in the Americas series on Anthropology-News]
At each consult with a pregnant woman, Doña Gabriela starts by asking: “Does your head hurt? Do you hear buzzing in your ears? Do you feel nauseous? Have you vomited? Do you see little lights?” After more than fifteen years of monthly trainings at a local clinic, these questions have become part of Doña Gabriela’s routine. Doña Gabriela knows that if the woman answers yes to one of these questions, called señales de alarma (alarm signals), it means that she (a midwife) might not be allowed to attend the woman’s birth:
If the woman has all of these [signals], then we won’t be seeing the birth, it is better if she goes with the doctor. This way, we come out clean. This is what we learn. (…) [When we get to the hospital] we just hand the woman over and that’s it. They don’t allow us in. We hand her over in the emergency room, that’s it. Before, they allowed us in, but now they don’t anymore. (Doña Gabriela, June 2015, interview with Jaime de las Heras)
State policies aiming to train indigenous midwives (parteras) gradually reshape their role in the health care system; indigenous parteras shift from being independent health care providers to becoming health auxiliaries — what I call alarm signal detectors.
Poster describing the alarm signals during pregnancy posted at Public Hospital, San Cristóbal de las Casas, February 2015. Photo courtesy Mounia El Kotni
Diminishing maternal deaths
Since the World Health Organization’s launch of the Safe Motherhood Initiative (SMI) in 1987, international efforts have focused on training Traditional Birth Attendants in hygiene (boiling instruments, washing hands) and encouraging them to refer women to hospitals. In this framework, pregnancy and childbirth are perceived as risky processes; with every pregnant woman potentially at risk of having a complication (Nicole Berry discusses the impact of the SMI and other international programs on Guatemalan women and midwives.) In Mexico, the combined effect of the International Conference on Primary Health Care (Alma Alta, 1978) which targeted “health for all, by 2000” and the SMI accelerated the construction of health centers in rural communities. Rural parteras trained in hygiene and the detection of alarm signals for referral to the hospital. Yet these one-size-fit-all recommendations, encouraged by international organizations such as the World Health Organization (WHO) and United Nations Population Fund, fail to take into account the realities of women in Chiapas.
Located in southeastern Mexico, the State of Chiapas has one of the highest rates of maternal and infant deaths of the country: 54.8 for 100,000 live births compared to a national rate of 38.2 (Observatory of Maternal Deaths in Mexico 2013). Chiapas is in many ways a unique place in Mexico. The Zapatista Army of National Liberation’s uprising in 1994 drew the world’s attention and the Mexican state’s interest to Chiapas’ million indigenous people (27% of the State’s population). In the past 20 years, the Mexican state has intensified its presence through government programs for farmers, road pavements, and the building of clinics. While these efforts have improved some living conditions, they have not always been successful. Still today, 74.7% of Chiapas’ population lives in poverty and extreme poverty (Secretary of Social Development, SEDESOL 2015).
Training indigenous midwives
In Highlands Chiapas, traditional indigenous midwives attend 70% of births. Following international guidelines from the WHO, the steps to diminish maternal mortality rates have focused on training these birth attendants. Mexican public health policies encourage practitioners in health centers and clinics to train the parteras in the detection of alarm signals; while on their end, parteras are urged to transfer their patients to hospitals.
The trainings for midwives focus on the opportune detection of alarm signals during pregnancy, birth and postpartum. The doctors and nurses who train them insist that the parteras learn these signals in order to recognize them and immediately transfer women to the nearest hospital. While opportune transfers have the potential to save the lives of the mother and child, government trainings do not discuss alternatives to transfer, in a context where the distance to the nearest hospital can often be of six or seven hours.
Given the cultural importance of birthing at home in Maya-speaking communities, surrounded by one’s family and in-laws, and with very little intervention, the shift from home to hospital is not only a change of physical place but also of space, social environment and language. In indigenous women’s and midwives’ accounts, the hospital is often described as an unfamiliar place with foreign codes; a dangerous place in which women are reluctant to give birth.
The coordinator of the Women and Midwives’ section of the Organization of Indigenous Doctors of Chiapas describes the impact of such trainings on the indigenous midwives, and the reasons why some of them slowly stop attending births:
It is like a rivalry that they are doing. It’s competition. For example… I attended this birth; but in reality no, I didn’t attend it totally. … I sent her to the hospital. If the baby is breeched for example, [the midwife will say] “It is breeched, better to go with the doctor… to go there, to receive her cesarean section.” This is what they tell women. Why? Because they have put a lot of things in her mind, in her heart… that the midwives once they have told us things, they believe it and start saying “Yes it is true that they die.” They tell them that they will send her to jail, that it will be her fault. They tell her “It is better that you don’t put yourself at risk by attending, better to send her to the hospital. It’s better. It is better in the hospital.” (Micaela Icó Bautista, Interview conducted by author, January 2014)
The paradox of insisting that parteras transfer women to hospitals is that even when they do so in cases of labor complications, they are still blamed for the situation. Parteras and mothers are scolded for attempting what is considered a risky birth — that is, trying to birth outside of the hospital. Because no one can enter with the laboring woman in public hospitals (midwives and husbands included), women will be on their own. Because the national policies urge midwives to send every woman to the hospital, public hospitals are saturated, and an efficient birth is a quick birth. The search for efficiency leads to routine episiotomies and skyrocketing C-section rates (Mexico now has the third highest C-section rate in the world).
Since there is a high chance women will be badly treated in hospitals, some parteras and family members refuse to send women to the hospital, even if they are able to identify the alarm signals. During births, parteras exert agency by evaluating the level of risk, comparing the risk of “something going wrong” and negatively affecting the mother and baby’s health, to the risk of going to the hospital and the bad treatment they and their patient might receive.
The negative impacts of training midwives touch at the root of the community’s health. When midwives stop attending births in their home communities, where they are the only health care providers, maternal and infant deaths will only increase. Despite international recommendations and government training programs, the reduction of maternal deaths in Chiapas will not be solved only by increasing the medicalization of birth. If the Mexican state does not focus on the root causes of such deaths — including structural violence, poverty, racism, and discrimination — indigenous women will continue to die in childbirth.