Wisdom of the Midwives

There was a knock on our apartment door....“Hay consulta!”  (There’s consult here!) one of the midwives said.  Essence (my student) and I were called into the prenatal room, as we normally are when a woman comes in for a prenatal check-up.  

Maria (not her real name) was in her last month of pregnancy.  Santos, the midwife on duty had already been checking the baby and when we came in the room, she asked Essence to go ahead and check.  Essence checked the position and then looked for the heartbeat but could not find it.  The baby was clearly moving so there had to be a heartbeat somewhere.  I stepped in to find the heartbeat and also could not find it.  I searched and searched while Santos stood by watching, patiently.  She waited for me to give up and then said,  “Donde esta la cabeza?”  (Where is the head?)  Only then, I checked for the baby’s position (duh) and the head was near the woman’s ribs.  The baby was clearly breech.  She must have found me humorous. “Allow me,” Santos suggested.  I stepped out of the way and she started her work.  She lathered up the woman’s belly with lubricant and explained what she was about to do--move the baby to a head-down position, which is much more conducive to a safe birth.  

She lubed up the woman’s belly with an herbal salve (Azucena makes all the herbal preparations) and began talking to the baby in Mam.  She translated for us, saying, “I’m telling the baby that the the doorway is not here, it’s over here, and he’s not going to be able to get out over there.  He has to move down here so he can get out.  I am explaining to him that he needs to move.”  All the while she massaged, and shook and jiggled the baby, with one hand on the baby’s head and the other on his bum, with sweeping massage motions in between.  She talked the baby through the whole thing and the woman lay completely relaxed.  For my own comfort I checked the heart rate before and after the procedure and the baby seemed to tolerate it quite well.

Within a few minutes she had a head-down baby, whom she instructed to stay there.  Maria was asked to come back in a week to make sure the baby stayed and that was that.  What we witnessed is something that Maya midwives have become known for, first through the work of Bridgette Jordan, who wrote about Maya midwives in Mexico in her book, Birth in Four Cultures, and then through the work of anthropologist Robbie Davis-Floyd, who has written articles and given many lectures, also about Maya midwifery in Mexico.  Here, they call it “componer el bebe,” or getting the baby in the right position.  In western obstetrics it has a fancy name--External Cephalic Version.  If it sounds intimidating, it’s with good reason.  In the U.S. it’s normally done under ultrasound and often with relaxant drugs and a lot of warnings about possibly needing to go into surgery if it doesn’t work or anything bad happens.  And only some obstetricians will do it.  Most will simply order a c-section for breech.  Some midwives in the U.S. do it but it is frowned upon, in my experience, because of all the fear and liability in the obstetrical world.  

Here in Guatemala, it is common to see a lot of babies that are lying sideways or in breech position.  I have my own theory about it that it has to do with the way the women wear their skirts, with a belt around the top that sometimes doesn’t leave a lot of room for the baby to get into the best position.  Whether or not my theory is accurate, when there is a midwife who knows how to get the baby back where it belongs with so little fuss, it becomes a non-issue.

In another prenatal visit, Essence and I had done our usual listening, measuring, and connecting with the mom and baby and as I was helping the woman sit up, it was clear she was in some pain.  Then Antonina, the midwife, said, “Hold on... i have to do her massage.  You don’t do this, do you?”  “No, “ I said, “go ahead.”   She put her hands on the woman’s big round belly and began to knead, and massage, and jiggle, and push and pull, all so gently and kindly.  “Suave,” she said.  Gently.  Chaba (In Mam)  In Mexico, they call it “sobada.”  Here they call it “masaje,” which just means massage.  She spent about 5 minutes on this massage, and as she did she explained, “This is one reason why the women like to come to the midwives.  The doctors don’t do this.  Often the woman will have a lot of aches and pains and when the midwife does her massage, she feels better.  That’s why they ask for it.”

Another thing we have have seen is the binding of the uterus after the birth.  Azucena took a wide belt and wrapped it tightly the morning after the birth around the woman’s hips.  She wrapped several times around and pulled hard and tight, like she was cinching it.  She explained that she was pulling tight to squeeze the hips because that in turn squeezes the uterus and helps the woman so she will not bleed so much after birth.  This is done for all women here with the idea that it aids in overall postpartum recovery.  I learned from Essence today that her great-grandmother, a granny midwife from southern Florida, did the same thing with her ladies, only she used a strip of an old sheet instead of a handwoven belt.  And that tradition was passed down to her daughters and granddaughters.

For me, there is much to be learned from working alongside these midwives.  And it’s not even so much about “technique.”  Techniques can easily be learned and transferred to other settings. It has more to do with their way of being.  Santos, for example, exudes a quiet confidence that puts women at ease and makes it easy to just follow her and do what she says.  I watched her in a life-threatening situation stay cool as a cucumber and do what was necessary to get the woman to the hospital.  I was totally shaken up after the event and it was her groundedness that helped me get back to equilibrium.  

And Antonina, for example, spends most of her time in the prenatal visits asking questions, telling stories, and making the women laugh.  I do way more laughing than midwifery skills in my visits with her. Unless you want to count humor among those skills. It’s about the way in which the midwives are so much like their clients, and that creates a certain integrity and continuity with the women they serve.  An ease and comfort and familiarity.  They dress the same, speak the same local language, struggle with the same issues of poverty, ethnic discrimination, and male chauvinism.  Antonina joked with one woman who’s husband had gotten her pregnant and then left as a wetback (or “mojado” as they are referred to here) for the states, “Well, at least you won’t have to deal with him for another 10 years.”  They all found that extremely funny.  

And then there’s Azucena (Lily)--keeper of the herbal wisdom.  The herb garden is her baby here at the clinic.  She gave us a tour and named every single plant and how it is used.  She even knows some of them in English because she has given talks to groups of American students and has learned them that way.  Various medicinal herbs are usually found drying in the special greenhouse on the roof of the birth center and huge bags of dried herbs are found in glass cabinets in the waiting room, along with special mixtures for urinary tract infections and other common issues in childbearing.  All of the midwives know how to use the plants but Azucena leads the way in these matters.

These midwives know how to keep a woman healthy with food, herbs, massage, loving and competent care, and good advice-- the things that are most accessible, and they know how to attend a birth in a way that makes sense to the woman and her family and makes the woman feel well-cared for on all levels--physical, emotional, intellectual, and spiritual.  These are the wise-women of the community.  It’s really clear.

When the midwives are in the clinic and not attending to women, they are cooking, cleaning the birth center, attending to the herb garden or working on weaving and handwork projects.  They may also be involved in meetings on any given day of the week.  There seem to be an endless stream of meetings.  Meetings with each other, meetings with other women’s groups, meetings with representatives from various groups to address issues of women’s rights, poverty, education, environmental contamination, and the encroachment of transnational enterprise.  I find myself deeply impressed with both the day to day talents I witness and the commitment to a larger vision of collaboration for change in this country.  I have much to learn here.

What on Earth is going on with the children?

Alma was laboring quietly and in her own world as we sat with her, waiting for the labor to do its work.  Ofelia, the midwife on duty, was very chatty that evening and began telling me about her son in the U.S.  “He’s 25 and he’s going to school and working in construction, “ she said.   I gathered she was proud of him.  The story was that he went to the U.S. when he was 16 years old.  A friend basically said to him, “let’s go.”  Ofelia was scared for his safety and did not want him to go.  The journey north, including crossing the Mexican and U.S. borders illegally, is a dangerous one.  Especially for someone 16 years old.  “And he made it,” I said.  “Yes, he did.  Gracias a Dios.  (Thank God.) A lot of them don’t make it.”

Last summer, when I was preparing to return to Guatemala I received several unsolicited warnings (by concerned people who care about me) about the worsening situation here, as exemplified by the news coverage of a growing crisis in the U.S. around child migration.  Thousands of unaccompanied minors are currently crossing the the U.S. boarder illegally every week from the northern triangle countries of Honduras, El Salvador, and Guatemala. 

 http://www.vox.com/2014/6/30/5842054/violence-in-central-america-and-the-child-refugee-crisis

A couple of weeks ago I was talking with my mother and told her that I had organized a visit to the Guatemala Human Rights Commission to get a briefing on the human rights situation here for women.  My mom was born and spent her childhood in El Salvador and has always maintained certain ties to Central America.  I am grateful that she asked me to do her a favor, which was to ask about what is happening on this end of the child migration crisis.  Why were so many children leaving?  She said the news media was not covering the story adequately and she and many people in her Quaker meeting in Minnesota were deeply concerned about the conditions of the detention centers (prisons) where the children were being held.  They wanted to understand what was going on and figure out a way to help.  

“What specifically do you want to know,?” I asked.  

“Anything,” she said.

I decided to take it on and see what I could find out.  I went to the human rights commission (ghrc-usa.org) with two other women and we sat and listened for 2 hours to a woman with over three decades of experience working in the human rights field in Guatemala.  I was not surprised when she told me she was planning on writing a book.  She was a gold mine of insight and information.

I asked her many things (mostly about women) and one of them was about the Guatemala side of the child migration story.  She didn’t miss a beat.   What I understand from all she told us is this:

There are three big factors effecting shifts in migration.  One is that there has been a cycle starting in the 70’s of migration that started with men going north, then their wives, and the children staying in Guatemala to be raised by the grandparents, with the parents going back and forth.  When the children get old enough they migrate for work, their parents stay behind to raise the next generation of children and the cycle continues.  This has been going on for the last 40 years.  But things shifted when the policy of deportation became more strict in the U.S. and many of these people were getting deported and the underground migration systems they had come to rely on no longer held.

The story of the migration cycle was confirmed by Antonina, the leader and visionary behind the ACAM birth center project, where I am currently working.  Somehow, without my even asking her, she launched into a lament about how so many people are going to the U.S. to make money.  And the “pobre abuelitas” (poor grandmas) are left behind to take care of their children by themselves.  She said that sometimes, if they are focused, they can make money and bring it back to their families.  But so many of them get lost, “perdidos,” in the vices of drugs and alcohol and they forget why they are there.  She said it is contributing a lot to the disintegration of family.

The second factor affecting shifts in migration is that between 2004-2007 there were a whole series of entire communities that were displaced to make room for large plantations of teak, sugar, and palm oil trees.  This created a desperate situation for these families.  She estimated about 424 communities, around 22,000 families were forcibly removed from their land.  This is a direct result of the Central American Free Trade Agreement (CAFTA) that allows companies to do this kind of thing, legally.  

And the third is about the business of human trafficking, which has become big business.  Families pay $8-10,000 US to “coyotes” who will bring their children north.  I was talking with one of the midwives at the other birth center where we were for a couple of weeks and she confirmed that this is indeed a huge issue in Guatemala.  “Where do people get that kind of money?” I asked.  She said sometimes they borrow it, or sometimes they will sell their land.  There is a certain desperation.  Families are sold on the idea that the children will be cared for and will have better opportunities to make money in the U.S.  Families also believe that the children are being protected by U.S. minor laws because the U.S. is not allowed to deport minors by themselves.  This, for now, is true.  What the families do not understand is that the children are being held in detention centers under horrible conditions.  All they know is that the children do not come back and parents are convinced that they have been successful in their migration.  Because of this, they keep sending more children with these coyotes, who are the agents of the human trafficking business.  Of course along the journey through Mexico, many children do not make it.  They get raped, robbed by extortion, or killed or they get kidnapped for drug trafficking or sex trafficking if they are the right sex and age.

The woman we spoke with explained that since 2008 there has been a steady increase in child migration to the U.S. and that in 2011 some of the children started to be deported by Mexico, only to return to the same dire conditions which they left, after their families had spent thousands in the coyote’s fees.  The number of children migrating rose in 2013 and the the U.S. was no longer capable of sustaining the phenomena and began to threaten to deport the children alone.  Currently, there is an active involvement of the U.S. state department to create safe houses for children in Guatemala and Honduras so deportation of minors can start.  

She explained that people send their children because of a naive belief in magic solutions to their economic problems, which she attributes to a shift to individualism from communal values.  This she ties directly back to the huge rise in evangelism, which promotes fear and the disintegration of communal interdependence through the concepts of individual salvation or damnation.  And parents believe the children will migrate successfully, because of U.S. child protection laws whereas the adults have a high chance of being deported.  She said something really profound about this that I really appreciated.  She said that you cannot get out of poverty by yourself.  You need the support of social and systemic structures to change the conditions of poverty.  I think this applies just as much to the U.S.

So all of these factors combine to create something that is quite a giant mess of a human situation.  The U.S. bears responsibility in some of this for CAFTA, which makes it legal for profit-seeking foreign businesses to enter the country and displace communities from their homes at will, for our heavy-handed immigration and deportation policies, for our double-standard of deportation and using the same people as cheap labor to keep the economic machine running, and for the exportation of evangelism (not a government thing, obviously, but it comes from our country) which promotes individualism, fear, and mysogyny, which keeps women oppressed and without a voice and that in turn prevents human progress overall. 

In response to the question of what concerned citizens can do in the U.S.  she gave this response:

COMPREHENSIVE MIGRATION LAW AND PRESSURE TO THE GOVERNMENTS OF GUATEMALA, EL SALVADOR AND HONDURAS TO CHANGE AND DEVELOP INSTITUTIONS (TOO MUCH TO ASK?

To learn more, go to the GHRC website:

http://www.ghrc-usa.org/our-work/themes/child-migrants/

Guatemala: a land of extremes

Lila (not her real name), with her pale skin and long silky copper-colored hair, came to the birth center for her post-partum visit with her new baby.  The midwife was concerned she might not come because of feeling embarrassed about the events leading up to the birth.  Lila had not come to the birth center in Guatemala City to have her baby as planned but had ended up with a c-section instead.

Lila had been seeing the midwife throughout the pregnancy and looking forward to a natural birth for her first baby, something that is becoming almost unknown in Guatemala City.  Another woman in the birth class we (my student and I) attended that evening said she had told her obstetrician she wanted a natural birth and he told her “natural birth is obsolete.”  To her credit she looked for, and found, a midwife.  

This same midwife, Hannah (a German midwife, trained in the U.S. and working in Guatemala) sat and listened to Lila’s story.  Lila had been feeling the pressure from people around her about having “passed her due date” by a couple of days.  She and her partner decided to get an ultrasound to check on the baby just for reassurance.  Hannah asked them to check back with her after the ultrasound.  While Lila was having the ultrasound the doctor became alarmed because the baby’s heart rate was 118 beats per minute.  (Normal is considered 120-160 on average so 118 is hardly worthy of alarm in absence of other issues.)  After Lila changed position the heart rate went up to 128, which is well within normal by any standards.  The doctor said it was still too low and ordered a cesarean that same day.  And that’s how she ended up with surgery after planning the whole pregnancy for a natural birth.

She sat on the couch in the birth center and as she told this story she began to sob.  She never expected this to happen.   And she said she felt like she had been fooled--  “baboseada” was a new word I learned.  The sense of needless loss of her birth experience and grief was intense and palpable.  There she sat with the fresh raw wound across her abdomen, unable to go back in time.

This story may sound absurd if you know anything at all about birth, but what is even more absurd is the fact that in private hospitals in Guatemala City, 90% of births are done by c-section.  In public hospitals 50% or more are done by c-section.  When the surgery itself (vs. vaginal birth) carries 4 times the risk of maternal death, in a country that already has one of the highest maternal mortality rates in the western hemisphere, not to mention the risk of infection and other complications, including physical and emotional trauma to both mother and baby, and the immense loss of the birth experience that I can’t even begin to unpack here, these statistics are talking about extreme violence against women and a crisis in human rights for women and babies.  Hannah called it sick.  I call it criminal.  To be clear, I don’t think any individual doctor is a criminal, but in my view the system that breeds them  to behave this way is criminal in nature.

I have, for my own reasons, a deep interest in protecting the basic human rights and dignity of women who are pregnant and giving birth, and their babies, everywhere in the world.  For me, supporting the preservation and development of midwifery is a key strategy toward that end of protecting childbearing women and their babies from unnecessary harm and guarding the sacred space of childbirth.

Somehow this lifelong passion has led me over and over to Guatemala, a land of extremes and perplexities.

I took my concern about this extremely unnerving news about the c-section rates to the Guatemala Human Rights Commission where I spoke with a woman I will not name here, a human rights veteran who has been working in the field for 35 years.  She was aware of the situation for women and birth and knew that women are not given any option about their births.  They go to a doctor and the doctor, most of the time, tells them they are going to do a c-section.  They don’t even tell her why a lot of the time.  There is no dialogue and often not even excuses about saving the baby.  She said if you ask them they will tell you that the student doctors need to practice and that’s why they do so many.  She said that women need to know that they have a right to decide what happens with their own bodies.  Women don’t even know that.

The women that find Hannah’s clinic in Guatemala City do know that they have a choice.  They are small in numbers but powerful in their determination and willingness to go against the grain that is all around them.  That takes a lot of courage in my book and I see these women as birth revolutionaries in the making.

One woman in the birth class took a half an hour or more to tell the story of her natural birth at the clinic in the most dramatic and entertaining way possible.  I could see her taking a microphone to talk about the importance of birth and creating change in Guatemala.  She was on fire.  Then her husband took his time telling his part of the story.  It was really beautiful to see such passionate energy from them both and a mesmerized room of expectant couples.

I was left processing this experience for quite some time afterward and thinking about the implications of a society without vaginal birth.  Forget natural, not even vaginal birth.  In talking with another midwife about it and asking what will become of humans without birth, she said, “we will be a very different kind of human.”

In most of the rest of Guatemala, a stark contrast exists.  In most places here there are not enough doctors by any stretch of the imagination to serve the needs of the entire population, for birth or anything else.  Midwives work mostly in isolation in rural areas, without adequate tools, sanitation, training, or support from the larger system.  Communities face hard choices about life and death on a regular basis.  Women face unbelievable challenges in getting basic health care and as a result many do not get the most basic care.  Many women die and many babies die, not because of any fault of the  midwives, but because of a system that is failing them in every way.  

Today I learned from another american midwife who has been involved here in Guatemala for a while that she was speaking with the Guatemalan Minister of Health at one point and he said to her about the indigenous women, “it would be better if they all die.”  So that’s the leadership in health care here.

The situation here is quite shocking and intense.  And I ask myself, what am I here for?  What is being asked of me?  I don’t know.  I can’t say.  What I can say is that I am following a lead from within and I will see where it goes.  First and foremost is to remain present with eyes wide open.  And not to turn away in the face of suffering.  But to make room for it in my heart and see where I want to go from here.

At the moment, I am landed for the next couple of months with my student, who has come to me through the Birth Institute study abroad program, at a birth center in the Western Highlands, ACAM.  ACAM is a women’s health center that is designed, owned, run, and staffed by indigenous midwives from the Mam area.  The women here are taking charge of forging their own path forward, creating a new history for themselves, and putting themselves on the map.  They are improving women’s birth options and women’s health and creating something that no government of theirs would ever give them.  They are stepping into their power in a big way here.  They are truly inspiring.  So this is a good place to be.  I am more interested in inspiration and positive change than in telling a sad story, though both are important to me.

In the few days we have been here, we have seen first hand how this place fills a vital need for the community:  a place where families can go to receive quality care that's culturally safe and respectful, a clean and and comfortable place to give birth where the whole family is embraced and women can give birth in a way that makes sense to them and keeps them in integrity with themselves and their culture.

So being here and seeing what I can offer is my next step.  I hope to have stories to share from here on this blog as time goes on.