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Training Professional Village Midwives

Emilio Godoy

SAN MIGUEL DE ALLENDE, Mexico, May 6 (IPS) - Mexican communications specialist Marla Vargas had her baby in the bathtub at home, attended by a midwife, because, she says, "I wanted a different experience, and a better way for my child to come into the world."

The practice of midwifery in Mexico goes back to the pre-Hispanic cultures of the people living in this land before the arrival of the conquistadors in the early 16th century. In many rural communities, midwives are the only option available for care during pregnancy and childbirth, as state health services are too far away.

But training for professional midwives is scarce in this country of 106 million people. The only officially accredited Mexican school of midwifery is run by the non-profit Centre for Adolescents of San Miguel de Allende (CASA) in this old colonial town 300 kilometres northwest of Mexico City.

"The school was created with the aim of giving women access to quality health care," Maricruz Coronado, a midwife and head of CASA since 2008, told IPS.

The organisation was founded in 1981, and its Midwifery School in 1997. Since then, 38 professional midwives have graduated, and at present 32 young women from all over the country, many of them daughters of traditional midwives, are being trained.

The World Health Organisation (WHO) defines a traditional midwife as a person (usually a woman) who assists the mother during childbirth and initially acquired her skills delivering babies herself or through apprenticeship to other traditional birth attendants.

Since 1919, professional midwives have had their own association, the International Confederation of Midwives, which currently has 88 member associations in 75 countries. From 1992, International Midwives' Day is celebrated every year on May 5, to honour their role in caring for the health of millions of women around the world.

CASA recruits its students from rural communities where the only health care for pregnant women is provided by midwives. After graduation, the young women return to their communities with knowledge that can be used to improve women's prenatal and childbirth care.

Students pay fees of 45 dollars a month, and the organisation subsidises their lodging, educational materials and uniforms. The entry requirements are to have completed secondary education, be at least 18 years old, and to come from a rural community.

Helping indigenous communities

"There are no medical services in my village. Women have to go to the nearest hospital, a journey of 45 minutes on foot and another 40 minutes by bus," Noemí Salazar, one of the students who is about to graduate, told IPS.

Salazar, a 26-year-old mother of two, comes from an indigenous community in the southern state of Veracruz.

Attendance by a midwife during childbirth reduces maternal and infant mortality and ensures healthier newborns.

"In rural communities, it is midwives who save the lives of mothers and babies," said Coronado, the head of CASA.

Mexico's morbidity rate during pregnancy, delivery and the immediate postnatal period (up to eight weeks post-partum) is nearly 50 percent, and the neonatal mortality rate (deaths of infants under 28 days of age) is 22 per 1,000 live births, according to official figures.

The maternal mortality rate is 52 per 100,000 live births.

National standards were introduced in Mexico in 1993, regulating the care due to women during pregnancy, childbirth and the postnatal period, as well as care of the newborn.

The professionalisation of midwifery involves systematising traditional knowledge and complementing it with medical approaches, in order to reduce the risks of childbirth and guarantee the health of mothers and their newborn infants.

When provided by midwives, "the quality of the woman's care is unbeatable; the timing of her labour and her needs are respected. She goes through childbirth well, and the baby is less stressed, adapts well to the outside world and is very attached to the mother," Coronado said.

The woman in labour can choose her position for giving birth, whether lying on her back, sitting, squatting, standing or in water. During labour she can have natural juices, homeopathic medicines and massages, and do some exercises.

Before giving birth, Marla Vargas took a six-month course to find out all about it and learn what to do during her labour, at which the midwife and her husband, mother, grandmother and sister were present.

"I didn't feel tired or exhausted, and I was never separated from the baby," Vargas told IPS, smiling as she talked about her five hours in labour and the birth.

In Mexico, 22,000 midwives attend more than 300,000 births a year in rural communities, according to official statistics. But this is an underestimate, as an unspecified number of women are known to have been left out of the count.

CASA midwives attended 345 births in 2008 and aim to increase that figure this year. In 2007, more than 135,000 births took place in Mexico's public and private hospitals.

According to the National Institute of Statistics and Geography (INEGI), the highest percentages of births attended by midwives are to be found in the southern states of Chiapas, Oaxaca, Guerrero, Tabasco and Veracruz.

These southern states are precisely the areas with the highest levels of poverty and the largest proportion of indigenous people, belonging to 62 different ethnic groups, each with their own languages.

The gift of life

Antonia Córdova, from San Miguel de Allende, is one of the six midwives who teach the birth attendants of the future, and one of those who has been at CASA the longest - since 1988.

"I became involved by chance, like all midwives. I found it deeply moving and I loved it, but later I saw the risks I was taking on," she told IPS.

Córdova, whose daughter graduated from the school three years ago and also works at CASA, can't remember how many births she has attended, but she is still awed by what she called "the gift of life," which she helps to bring about without trauma.

At CASA the study programme lasts three years and includes subjects like biology, anatomy and gynaecology. The knowledge and skills students learn here won their midwifery course the highest score in a 2006 study of three Mexican programmes.

In an assessment of 223 different variables by the National Institute for Reproductive Health in New York and the Department of Obstetrics, Gynaecology and Reproductive Sciences at the University of California-San Francisco, the CASA programme was awarded a score of 85 percent.

The second programme was the National School of Nursing and Obstetrics at the state National Autonomous University of Mexico, which combines midwifery training with nursing certification, and was awarded a score of 54 percent. The School of Medicine at the same university obtained 45 percent on the evaluation.

CASA emphasises team work and interpersonal relations; advanced students help those with less experience, and they encourage team building within the midwifery community, the report said.

In contrast to countries like Chile and Argentina, midwifery is not a university degree in Mexico, and there are many hurdles to its integration with the health services, Coronado said.

"Midwifery could be taught on a large scale, which would yield better results, while educating women," said Débora Clavé, the principal of CASA's midwifery school. Clavé, who is from the southern Argentine province of Chubut, came to CASA as a volunteer and has been coordinator of the education programme since July 2008.

In addition to the midwifery school, CASA runs 10 other projects, including a hospital and a daycare facility for children aged between two months and three years.

Now the organisation is seeking to open similar midwifery education centres in Oaxaca and Chiapas, and in the Central American country of Guatemala, on Mexico's southern border, where there are an estimated 20,000 midwives.

***** + Débora Clavé and Maricruz Coronado. Credit: Emilio Godoy/IPS. ( + Midwifery students in class. Credit: Courtesy of CASA. ( + PERU: Birthing Houses Combine Native Traditions, Modern Medicine ( + DEVELOPMENT: Presidents Boost Maternal and Child Health ( + HEALTH-AFRICA: Bringing Traditional Birth Attendants Into the Mainstream - 2006 ( + HEALTH-KENYA: Do Safer Births Require a Break With Tradition? - 2005 ( + HEALTH-PAKISTAN: Dearth of Trained Midwives Plagues Planners - 2003 ( + Centre for Adolescents of San Miguel de Allende, CASA ( + International Confederation of Midwives (