How a marriage of traditional and modern midwifery is transforming lives in rural Mexico

"They hold in their hands the future of the communities” - Gabriel García Salyano, Global Pediatric Alliance

Ruiz comes from the Chenalhó municipality in the highlands of Chiapas state, on the southern Mexican border. Chiapas is a region of dense forests and rich natural resources, but it is also one of the poorest areas of Mexico, with about 74% of its inhabitants living in poverty. About a third of people in Chiapas are indigenous Mayans, and for many, lives are still lived in very traditional ways. In remote areas, people live largely off the land with little access to public services. Getting medical treatment requires travelling long distances often on foot, to the nearest town. Parteras have been relied on by rural communities there for generations, as not just midwives but also healers and spiritual advisors.

Ruiz is one of at least 5,000 traditional midwives in Chiapas state, according to official figures, although she believes the informal nature of the work means the real number may be much higher. About one in three births in the state are attended by a traditional midwife, she says.
Traditional midwifery has always been a craft which deeply values inherited wisdom. While Ruiz did attend some medical training early in her vocation, she also “received knowledge passed on from generation to generation”, from her grandmother and mother, who were also midwives. Like the parteras before her, she learned skills like which herbs to collect
from the land and use to make teas for mothers, how to give massages to move labour along or manage pain, how to move a baby into position, and to care for it in the moments after birth.

The midwives, who are not paid or take only voluntary donations, are deeply respected within their communities. But it was when Ruiz decided to study midwifery more formally at nursing college that she realised there were barriers to gaining the same respect among medical professionals.
For much of the late 20th Century, hospital births were strongly promoted under national health policies in Mexico aimed at reducing maternal and infant mortality. By the late 1990s, the vast majority of births were taking place in hospitals, while the medical profession made it increasingly difficult for the parteras to continue their work, seeing it as an outdated or even dangerous form of patient care.

Ruiz says that in some states, these policies have resulted in traditional midwifery being almost entirely wiped out. In Chiapas, however, it has clung on, she says. "Many women in Chiapas still prefer to be treated by us because of the care we provide, because of the trust they have in us, because we speak their language, and we treat them according to their spiritual worldview,” she says.

There are times, however, when the care a mother or baby needs goes beyond the abilities, training or resources of the parteras. If a traditional midwife is unable to access medical help for the mother for any reason, or does not recognise the need to do so, the consequences can be devastating.

In 2012, Chiapas recorded just under 60 maternal deaths per 100,000 live births, 40% higher than the Mexican average. A wide and complex range of socioeconomic factors, and cases of abuse or poor treatment by medical staff, mean indigenous women in Chiapas have an up to five times greater risk of dying in childbirth than other women in the state.

The Nich Ixim Midwife Movement of Chiapas, for which Ruiz is a spokesperson, was formed in response to these challenges. This collective of 600 midwives from more than 30 municipalities, works to preserve their traditional craft and advocate for its continuing value in contemporary healthcare. But a founding principle is that Nich Ixim members commit to continually updating their skills, so they can provide the best possible care for mothers and babies.

“We midwives are open to training, as long as it respects and recognises our knowledge, experience and us as individuals in charge of the health and life of our people,” says Ruiz.

In 2014, Nich Ixim began working with health and development NGOs in Chiapas on a series of workshops bringing midwives together with medical workers, and exploring ways in which both could learn from each other's skills and traditions.

"This knowledge... is valid knowledge,” he says, arguing that Western medicine can learn from the way in which midwives respond to the needs and wishes of a labouring woman. Rather than a doctor being in control, it is the mother who is “the protagonist of the process, she is the one who is in charge of the birth, the one who can make decisions and decide how to be cared for”.

Dr Salyano is reluctant to call himself a trainer because !it sounds to me a little bit as if the women have empty heads and we have to fill them”. Instead, he says the workshops aim to “create a dialogue of experiences” between midwives and medical staff, working together as equals. The workshops create a space for the midwives to talk about their experiences or challenges without judgment, he says, while the physicians and obstetrics specialists can step in to suggest what solutions they could be trying, where they would need to seek urgent help, or to demonstrate useful techniques like how and why to monitor blood pressure.
Where the midwives discuss a technique they use which the physician views as dangerous for the mother or child, he says, !we put reasons or arguments as to why such a practice is not the most appropriate,” he says. But at the heart of it, there is always a deep respect for the midwives and their ancient craft.

“We say that midwives hold in their hands the heart of the communities, the women. And they hold in their hands the future of the communities, the babies. So, this is very important work,” he says.

Dr Salyano says it's hard to measure in figures what impact the workshops are having, but that he knows there have been no maternal deaths among the midwives they have worked with, and that !many midwives have managed to transfer women in serious situations to a
hospital where they are treated. And that is saving lives”. But the workshops have also helped the midwives feel a new pride in their work, he says, and “that they no longer feel that it is a lesser or unimportant profession”.

For women like Eustaquia Ruiz Gómez, who lives in an even more remote village in Chiapas, knowing that traditional midwifery is being preserved but also enhanced by Western knowledge has been hugely comforting.
“I really liked the work of the midwives because they took good care of me,” says Gómez through an interpreter, as she cradles her one-month-old daughter, delivered safely in the calm and familiar comfort of her home by a traditional midwife.

"The traditional part is important because women are seen at home. They use more natural plants or natural herbs," she says. "It’s not the same as when we give birth in a hospital, because they don’t let the midwives give us a hot tea or something like that.” Gómez believes that "midwives in every village are what we need the most,” but she also acknowledges that expanding their skills is "a step forward too, because they are going to
have more experience. When they can’t help a woman at home, they now know where they can take her or where they can help her more.”

‘We believe our work is crucial’

Dr Salyano shares a story which illustrates just how well the workshops have become integrated into the cultural traditions of the midwives.
A woman attending the workshops told him she had had a frightening recurring dream that she was attending a birth where there were serious complications, and she did not know what to do.

“But one of the times she dreamt this, she dreamt of me and I told her not to worry,” says Dr Salyano. “That when the birth came, yes, she was going to have complications, but that I was going to be with her to tell her what to do.”

Later, when the woman was attending a birth and just that complication arose, it was something she had studied in one of the workshops, and her new training kicked in. “She remembered what she had to do, the hand movements, what she had to work on. And the birth went well in the end.” Says Dr Salyano. For him, stories like this show the value of the workshop approach to training. The midwives, he says, “take these experiences, this
knowledge, and in their own way, make it their own”.

“We say that knowledge complements other knowledge, enriches it. That is what we want to do with the midwives, and obviously by working with them, we also enrich ourselves.”

Ruiz says the global pandemic has illustrated just how valuable midwives are in their communities. As hospitals were closed for lack of staffing, or dedicated to treating Covid-19 patients, many more mothers turned to traditional birth attendants. “There were midwives who doubled their workload,” she says. “[But despite this] situation, maternal mortality in Chiapas did not officially increase.” She puts this success down to the
work that Nich Ixim has done to raise the profile and reputation of midwifery and to the value of traditional skills.

"That is why we midwives believe that our work is crucial and that working as a team with the health sector and with other professional midwives is necessary, so that women have access to more options for safe, timely and quality care.”