Hoping to Curb C-Sections, Midwives Fight for Relevance

OAXACA DE JUÁREZ, MEXICO — Araceli Gil, a midwife for 19 years, says doctors and nurses scold her clients for using her services.

Hermila Diego, another midwife, says a president of the Oaxaca College of Gynecology and Obstetrics once urged her to stop attending births. Midwives are dirty, he told her.

And in Puerto Rico, midwife Vanessa Caldari says some physicians put the babies she delivers on antibiotics for a week in the neonatal intensive care unit.

For centuries, midwives in Mexico and Puerto Rico delivered most of the children in their communities. Today, in both places, they are fighting to reassert their relevance at a time when they say their skills are desperately needed.

“How could [the doctor] question my work if in my now 70 years of midwifery never a baby has died in my hands?” says Diego, 87, who belongs to the Zapotec indigenous people.

Their urgency speaks to an alarming number of cesarean-section births in Latin America and the Caribbean, reflected in the high rates of the procedure in both Mexico and Puerto Rico. Their struggle also reveals the unintended consequences of cultural and technological change.

As late as the mid-20th century, most mothers in both Mexico and Puerto Rico gave birth at home with the help of midwives. By the 1950s, Puerto Rican midwives outnumbered physicians 2-to-1.

As medicine grew more efficient and technology-driven in these regions and worldwide, midwives found themselves increasingly sidelined.

Ena Aguilar Peláez, GPJ Mexico

Araceli Gil, a midwife, gives client Raizza Ketzali a full-body massage to help her relax and feel stronger. Ketzali attributed her stress to the pandemic.

Meanwhile, a crisis was brewing. C-sections, rare when midwives performed most deliveries, became increasingly common. In Latin America and the Caribbean, 44% of births in 2015 were performed by C-section, according to The Lancet, a medical journal – the highest rate in the world.

In 2016, the rates in Mexico and Puerto Rico were about 45% and 46%.

Mothers who give birth via C-section suffer more infections and hemorrhages, and their babies are more likely to have breathing problems, according to the American Pregnancy Association. The maternal mortality rate is also higher for C-sections, the organization says.

Most births in Mexico and Puerto Rico now take place in hospitals, which experts say has driven up the rate of C-sections. Mexican midwives attended about one-third of births in 1985, according to Mexico’s National Institute of Statistics and Geography. By 2018, that figure had nosedived to 3.6%.

The World Health Organization, echoing numerous studies, has reported that when midwives take part in deliveries, fewer C-sections result. Caldari, who runs a nonprofit called Mujeres Ayudando a Madres (Women Helping Mothers), says that of the births attended by the organization’s midwives last year, only 14% required C-sections.

“We can provide care during a birth using the latest knowledge, but balancing it with what’s organic,” Caldari says.

Yet in both Mexico and Puerto Rico, many midwives can’t work formally with hospitals or doctors.

The only certified midwives in Puerto Rico are those who have studied in the United States and earned professional degrees. About 10 midwives, including Caldari, are certified professionals with the North American Registry of Midwives, but Puerto Rico’s government and hospitals do not recognize that certification.

Midwives in Puerto Rico work only with families. Health insurance plans don’t cover their services, and they can’t accompany clients into the delivery room.

The Mexican Ministry of Health offers a certificate to traditional midwives, but only if they adopt conventional medical practices, such as giving drugs to mothers during deliveries.

Ena Aguilar Peláez, GPJ Mexico

Cipatli Velasco, right, sits next to her mother, Hermila Diego, who has been a traditional midwife for seven decades. Velasco learned alongside her mother, and in 1997 she attended a midwifery school, where she was certified as a professional midwife.

The agency had certified 7,000 midwives as of 2016, in addition to hundreds of professional midwives. Traditional midwives in Mexico who aren’t certified by the Ministry of Health cannot attend births and must send clients to a hospital to deliver.

In the southwestern state of Oaxaca, Mexico, Gil runs a school that embraces both traditional midwifery and the internationally recognized requirements of professional midwifery. But the Mexican government doesn’t certify its graduates because some teachers are traditional midwives.

“We feel that there is no real recognition of the diversity of medicine in Mexico,” Gil, 48, says.

Some doctors in both Mexico and Puerto Rico doubt the skills of midwives.

Dr. Nabal Bracero, an OB-GYN with offices in San Juan, says that while trained midwives can support a mother through birth, they should only assist obstetricians.

“What we don’t want is to go back in time,” he says. “If we want to care for the patient, it’s going to require [midwives] to be up to date with technology and all the advances that are available to [them].”

Coraly M. Cruz Mejías, GPJ Puerto Rico

Rebecca Z. García, a midwife, and Camila Seda Rafucci, a doula, assist Sharon Rodríguez, who is pregnant with twins. García is part of Mujeres Ayudando a Madres (Women Helping Mothers), a group of midwives that helped pregnant women in affected areas after a major earthquake shook Puerto Rico in early January.

In both regions, many medical authorities and midwives agree on one thing: The number of C-sections is too high.

Puerto Rico’s government has ordered hospitals to craft policies to reduce C-sections, and has said hospitals should stop performing elective deliveries before 39 weeks. The goal is to cut the C-section rate to about 35% of births by 2026.

In recent years, Mexico’s government has issued more stringent clinical practice guidelines regarding C-sections, and the national legislature has proposed bills to reduce the frequency of the procedure.

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Some experts say one way to reduce C-sections is for doctors and midwives to team up. But the dynamics can get complicated.

Marianela Lira, who lives in Puerto Rico, was a first-time mother who used both a midwife and a doctor three years ago. The doctor wouldn’t allow the midwife to attend the birth, an unexpected C-section.

“I perceived that he was the boss,” Lira says of her doctor. “Imagine. He didn’t let her come to my delivery. I think that was unethical.”

Ironically, fear of the coronavirus has compelled more pregnant women in both Puerto Rico and Mexico to shun hospitals for midwives.

Priscila Chávez, a midwife who runs a birth center in Oaxaca, says that before the pandemic, she attended one or two births a month; now, she attends three or four.

In June, Gil left her house at dawn for the home of an expectant couple. Armed with a birth chair, shawl, electric cushion and other equipment, Gil set up in the couple’s study, where the mother-to-be planned to give birth.

Gil applied essential oils to keep her client relaxed and offered her hot chocolate, fruit and water mixed with honey and lemon.

Quiet and calm, Gil also monitored the woman’s vital signs and the baby’s heartbeat, gave her massages and touched her belly to check the baby’s position.

More than 12 hours after Gil arrived, the mother delivered in a birthing chair. Afterward, everyone – tired, sweaty and emotionally drained – dined by a terrace fireplace.

It was a boy.