by Cathy Huang:
Salud Alarcon, 15 years old with brunette ringlets framing her grinning face, has written her favorite saying onto the first page of every fresh notebook she purchased for school: “No hay mal que dure cien años.” There is no evil that lasts 100 years. There is nothing one can’t endure.
For Salud, whose mundane high school routine in Antigua, Guatemala presents her few real stressors, this saying reminds her that she is lucky. She entered the world on a humid evening in February, barely surviving a fight against her mother’s umbilical cord, which had wrapped around her, trapping her inside her mother’s uterus.
A woman’s first labor lasts, on average, eight hours. Salud’s mother was in labor for over twenty painful hours before hemorrhaging to death after Salud was finally extracted. The birth attendant left the house with few things to say. Salud’s father prepared a low-key funeral. Two years later, he remarried.
Of the 500,000 women’s deaths each year from complications that arise during childbirth, 99 percent occur in developing countries, where a woman’s lifetime risk of dying from pregnancy and related complications is almost 40 times greater than that of her counterparts in developed countries. A woman’s risk of dying in childbirth in the United States is one in 3,700 whereas in Latin America the risk is one in 130. In Guatemala, with its 13 million residents, a population that doubles about every 22 years, promising natural resources and mounting tourism, the maternal mortality statistics are more than sobering—they are unacceptable.
With the second most skewed income distribution in the Western hemisphere, Guatemala is split, geographically and culturally, between the rural indigenous people of Mayan descent who carve their villages in the highlands, and the urbanized Ladino population. As estimated by Hurtado and Saenz de Tejada, the Ministry of Public Health and Social Assistance in Guatemala, there are 248 deaths out of every 100,000 live births. Maternal mortality among indigenous Mayan women in certain rural areas, however, may be as high as 446 in 100,000. These statistics make pregnancy in Guatemala more dangerous than pregnancy in any other Latin American country.
The causes of maternal mortality in Guatemala, the most common of which are postpartum hemorrhage, puerperal sepsis (a bacterial infection of the blood), or eclampsia (unmitigated seizures) are all attributable to abnormally prolonged labor that is quickly detected by trained obstetricians. But the majority of rural Guatemalans who speak indigenous languages and practice centuries-old home remedies will never set foot in a hospital. Not surprisingly, the health of indigenous Guatemalan mothers and children is dramatically poorer than that of the Ladino population. Rural women will only trust their local midwives at their bedsides.
Traditional midwives attend 80 percent of home and in-clinic births in Guatemala and virtually 100 percent of births in rural areas, where drug-less, tool-less home birthing is the only option. Unfortunately, there are only 20 trained midwives for every 10,000 Guatemalans. But Western medical training might not yield lower mortality rates: Several field studies suggest that many obstetrical routines have cultural rather than medical determinants. In the mid1990s, an independent researcher hired by the World Health Organization to survey routine obstetrical practice around the world concluded that only 10 percent of all routine obstetrical procedures were scientifically based. The evidence points to childbirth as a largely cultural or spiritual event in a woman’s life.
“[Some] rural midwives bring relics to the bedside,” said Dr. Jean Albright, the director of a global health project at the University of Michigan designed to expose medical students to the ethnic, religious, and linguistic barriers to equalizing rural health care access in the Guatemalan highlands. “Some of the traditional communities in the highlands don’t have what we refer to as ‘biomedical beliefs.’ They simply don’t get the point of hospitals or physicians.”
Albright had to send her first batch of student health workers back to Ann Arbor so she could spend a year calibrating the program to better suit these ethnic divides. Understanding midwifery, traditional or otherwise, precedes any attempts to build hospitals or wrestle with a corrupt and Ladino-dominated national health care bureaucracy.
A targeted global health intervention will wisely select the most instrumental player in the rural childbirth gamble, the comadrona, the traditional midwife, as the locus of progress. But do researchers and global health workers force midwives to speak their jargon of elapsed seconds, bacterial this or that, pre- or ante-natal precautions, or do they try to make room in their proposed professional and results-based interventions for the fact that childbirth is spiritual before it is medical?
Jennifer Houston, a practicing midwife in both Antigua, Guatemala and Catskill, New York, believes in the latter.
“Traditional midwives have knowledge and skills that are unique and different from the biomedical or ‘technocratic’ model,” she argues. “The unique gifts that traditional midwifery has to offer, unexposed to biomedicine, is a profound trust and belief in the sacredness of birth and women’s power.”
Nearly 15 years ago, Houston founded Ixmucane, a birthing center disguised as a quaint colonial house in the narrow streets of Antigua. The center hosted several foreign nurses each year who paid nominal fees to a local comadrona for several months worth of home cooking and for cot space. Upon arrival, the foreign nurses would shadow their midwife hosts for several weeks under a program called Midwives for Midwives. Houston, whose birthing center was forced to close after the national government dropped its promised funding, emphasizes the need to respect the sanctity of childbirth.
Midwives for Midwives still facilitates home stays, and while visiting nurses must submit reports about tools and educational methods they believe would best work in fighting prolonged labor in rural contexts, there is little mention of offering professional instruction—no “graduation” or approval system for a midwife’s skills— only culturally adapted suggestions for preventing life or death situations.
“We’re working to reverse the global trend of devaluing traditional systems, and to prevent the natural process of birth from becoming a total medical and technological procedure done to women,” said Houston resolutely. Her tone, authoritative and fearless, suits a woman who delivered all of her own children at home with only herbal medications.
Pregnant women in developed countries often enter labor under the much-appreciated spell of an epidural. Whether at the preventative stage, through the use of contraceptives, family planning, shopping for an ob-gyn, or during delivery itself, being able to choose drugs or agree to Caesarean sections, women have choices. But in countries like Guatamala, where the perspective insisting that women exist to deliver is still prevalent, birth, as Houston argues, is done to women.
By allowing rural midwives to host educated, foreign nurses, and by making room for their ritualistic or “unscientific” birthing methods, exchange programs like Midwives for Midwives aim to empower midwives by letting them know that their jobs are valued. Even if biomedical childbirth with its blood pressure cuffs and cervix dilation readings remains a foreign concept in the Guatemalan highlands, midwives learn that their art demands skills—skills to be shared and developed—and that they possess a gift rare among women in their rural communities: an education.
But according to Daniela Adabi, exchange and cultural accommodation is not enough. Abadi’s missions as a midwife with Doctors Without Borders have taken her to Cambodia, Thailand, Nicaragua, and, most recently, back to her home in the lush valleys surrounding Lake Atitlan in southwest Guatemala. It’s there that she plans to launch a professional midwife training center. Abadi, a French-educated Argentinian, speaks slowly about her experiences with maternal mortality, enunciating her syllables above the rapid metronome of raindrops on her corrugated metal roof.
“The responses from the local women have been good. Most of them accept the idea that things need to be improved,” explains Abadi, whose proposed project will recruit graduating high school senior girls and offer them professional obstetric training, the kind dispensed to home birth attendants in the United States. Abadi’s model replaces home stays with on-site instruction, and will collaborate with local universities to provide some sort of initial certifications for its first graduates.
“This will be a model where you don’t just impose on the women where to give birth, how to give birth but also [provide] workshops, classes around nutrition, around child care.” Abadi, unlike Albright or Houston, is a local. Health workers dream of places like Lake Atitlan, with its lush climate punctuated by the occasional intense rains and its hushed Mayan tradition tucked into all hours of the day, but Abadi knows the local school systems, some of the local midwives, and has faith that her proposed model has calibrated itself to fit the culture.
For the few women who complete their high school education in the Atitlan highlands, there are few skills-based jobs. The only other alternative in the health professions is assistant nursing, which tends to be less appealing than marrying young and rearing children. And while Abadi concedes that “there [will be] a lot of challenges” to her model, the biggest challenge will be to have trained midwives recognized by the community they serve and by the national health system. But by reinforcing technical education and offering a program that a midwife can say she graduated from, women can find confidence in their skills and status. And the introduction of professional midwives could be empowering in new ways, too.
“[Women] choose the traditional birth attendant because that is all they know. That’s the tradition. But if you have trained professionals, women can ask for what they really want and what they really need … not just feel like they have to say ‘yes’ to anybody.”
Childbirth is spiritual and empowering. But it sometimes involves no choice for the women involved. Childbirth is, for many women, a celebration, a milestone. But childbirth can be deadly.
In Xelaju, Salud Alarcon is studying to become a doctor. She regularly complains about her homework and often procrastinates by playing soccer at the gimnasio downtown. Her urban upbringing affords her the opportunity to study in school and pursue higher education. It even has her considering an unlikely path to medicine.
“Maths is so hard,” she mumbled. “But it will be worth it. I want to make people feel good.”
Over the years, Salud’s voice has developed an undeniably warm, maternal timbre. Despite harboring the usual teenage anxieties about boys and fashion, she speaks to her younger step-siblings and shares her career dreams with a mature inflection. One day, she will live up to her name and might even, as a physician, help propagate what it represents. “Salud” in Spanish, after all, translates to “health.”
For women in the rural highlands, the legitimization of existing female roles, as midwives and valued homemakers, is the closest thing to female professional development. Whether the process will involve ritual exchange or diploma exchange is unclear. But a woman’s agency rests at the center of every movement to fight maternal mortality. These movements offer the promise of education, of cultural understanding, and of advanced medical methodologies. Above all else, they offer women the ability to choose health in the face of tradition.
Cathy Huang ’14 is in Morse College. Contact her at cathy.huang@yale.edu.