In this piece, Debbie Díaz Ortiz, an independent professional midwife and great-granddaughter of midwives in an isolated community of Puerto Rico, illuminates the power of terminology. She brings to light how the re-naming of the midwives who learn and practice in rural communities around the world as “traditional birth attendants” has had a damaging impact on these women and their important role in the communities they serve. Debbie encourages us to return to the term “midwives” to refer to these critical care providers, so that they receive the respect, acknowledgement and resources that they deserve.
Around five decades ago, the term midwife began being replaced by the use of the term Traditional Birth Attendant (TBA) in the international context .
Midwives in remote regions of the world learn as all of our midwifery ancestors in the world have – in a manner that is considered informal by some: through her own experiences as a mother, assisting other women, or from her ancestors, colleagues, healers, and other health providers in her community. It also common for her to learn through means of self-learning – including dreaming, taking examples from nature, or allowing her spirituality to provide guidance for her work. These midwives have been, and still are, extremely important teachers to professionals and vice versa. They are health guardians, and they have the right to develop from their roots.
By the year 1970, the term Traditional Birth Attendant (TBA) had already appeared in a document intended to improve maternal and child health as part of the Safe Motherhood Initiative from United Nations Population Fund (UNFPA). Concurrently, many communities use as habit the voice midwife: The uses of a word by custom in a country technically makes it legal; therefore, village use of the name (midwife) is strong as UN uses of the phrase TBA: Although, UN definitions may be use legally still just suggestions from outside the country.
During the last decades of the 20th century, international programs were most directed to help midwives in isolated areas. By the year 2000, the goals set forth for the new millennium by United Nations only promoted professional midwifery services for all, implying that the midwives from the villages ( referred as traditional birth attendants) were supposed to simply accompany women, while referring them to the professionals. And, the midwives from isolated communities should only work as midwives when there is not a pro to take charge, if at all.
Shortly after those changes, Latin America began to report, (1) more mistreatment during transports and in hospitals, (2) less supplies than previously received from governments and NGOs (3) no personnel available to send to the communities for continuing education and other matters, (4) lack of transparency from the professional care providers. What’s more concerning is that the disconnection of midwives from their roles is not as prolific in Latin America as it is in Asia and Africa where the WHO has more of a focus.
Furthermore, according to several studies (PAHO, 2002; Goodburn et al, 2000; Schieber et al, 1994), there are flaws or deficiencies in the international programs supporting midwives in isolated regions. Unfortunately, the WHO has turned a blind eye to these flaws, which are documented to be:
- Inadequacies in education/ curriculum;
- Lack of continuous support, and;
- Lack of integration of the traditional midwife to the local health programs.
After these studies, there is no subsequent documentation that shows that these inadequacies are being dealt with.
In 2004, the World Health Organization wrote the document Making Pregnancy Safer: The Critical Role of the Skilled Birth Attendant. In the document it is mentioned that it is a tramp to put effort in training and raised concern about the re-naming of midwives in isolated regions, prompting that in 2008 midwives from these regions in Latin America organized and asked that the global community reinstitute the use of the term midwife and to be respected as a labor force; they also share sensible successful inclusive models. The midwives of tradition within the Latin American Alliance of Midwives in conjunction with Relacahupan achieved to do the first two weeks world wide cyber-forum of midwives The Global Forum on Traditional Midwifery, hosted by the Spanish section of the Global Alliance of Midwifery and Nursing.
The precedent set forth by the WHO that allows midwives in isolated regions to be systematically excluded, was considered absolute and followed without doubt at the time by the UNFPA, the United Nations, and the International Confederation of Midwives, and later, the White Ribbon Alliance for Safe Motherhood. The impact of these organizations and these programs is profound and far-reaching.
It is worth mentioning that in-depth analysis shows that professionally-trained midwives only go to isolated, resource-constrained regions for short periods of time. It is not common for them to establish a life there with their family to provide constant support, and that governments do not have the money to accommodate professional midwives in every isolated community. In addition, studies demonstrate problems in maintaining adequate clinics. We must consider that in just one town of one developing country you may find more than 100 clusters of neighbors who live in isolation with no transportation.
Very significant is the lack of balance in the support of midwives in their settings, efforts to improve maternal mortality rates by reaching United Nations Millennium Development Goal Number 5 have actually been harmed. Overall, the maternal mortality rate did not achieve significant improvement between 2000-2015 – only around 1% in 13 years so far.
According to studies and experiences around the world, here are some suggestions for what works to support isolated midwifery:
- The recognition that mothers should be the basis for the creation of sustainable programs, and that the traditional midwife is an option they do choose.
- Transparency, equity, harmony, and horizontal relationships among care providers.
- Validation of traditional learning methods, including memory and experience.
- Acceptance that the work and training of the traditional midwife contribute to the reduction of mortality in their communities.
- Public health programs for regions with minimum resources.
- Support for contraception and acknowledgment of other ways to avoid pregnancies.
- Acknowledgement that monthly reunions are essential in order to have successful programs to:
- Review of the cases among them or in collaboration with professional midwives or other personnel;
- Check the supply of materials and medications, and create strategies to obtain more, and;
- Maintain reciprocal and continual education.
It’s important – basic, core – to understand that programs do not have to be long or expensive for success, in fact the most effective programs are short, NGOs or friendly to the government.
Here are the details of programs that have reduced maternal mortality to zero or near zero:
- A 4-day course with lecture and clinical practice from Relacahupan and Peace Initiatives: Includes integral health, eating local and traditional foods, managing infections and emergencies and support long term exclusive breastfeeding. Year-long supplies of medications are distributed, including medication for anti-hemorrhage (in general they do not ever need to use them). This program has reduced maternal death to zero for two years in a very distant, poor community with no other medical resources (details of program at www.escueladaraluz.net).
- An agricultural program sustained by midwives and mothers in Sierra Leone, in which anti-hemorrhage medications are also supplied. This program reduced maternal mortality to zero.
- A course of 12 classes and a meeting once per month that includes peer reviews, materials check, and continual education. This was a government program in which the midwives statistics were significantly superior to the other providers in terms of maternal mortality and health.
- Samoa is an entire country oriented to support for the traditional midwives. They actively unite professional and traditional midwives, giving awards to the best ideas to make a mother base system to work socially and politically. In this way, they have achieved excellent results. (Other data resources given, reference at the end)
There is much hope for all midwives to re-gain balance and respect in their roles and communities to have a huge impact. Today I see many midwives helping others, sharing in reciprocity and looking for their local resources that are consistently available to protect the health of mothers and babies; I see culturally adequate organizations establishing clinics in needed areas; I see midwives working where natural disasters occur; peers visiting different isolated communities with sister midwives and loving their continental long journeys; I witness conferences that emphasize and assist the roles of midwives from isolated areas; I see others sharing what countries have done to unite all midwives in transparent manners and harmony, continents uniting in ideas, books with more images and less words, an international definition for them, a definition that unites all midwives from the International Alliance of Midwives (IAM) and these international organizations latent and available in case midwives need before their governments. All of these and more are helping to improve the status and support structures for community midwives.
Someday the World Health Organization, the United Nations and others will join with their resources, and perhaps go about their programming in more pragmatic ways.
The only way I know how to work in another country or group is by first asking how I may collaborate, and then learning by doing, do work, reduce mortality, simply the humane way.
- Definition of the Traditional Midwife by Relacahupan at, The Traditional Midwives in Our Region. http://www.relacahupan.com.ar/parttradeningles.htm,
- Definition of all midwives included at http://www.midwiferytoday.com/iam/
Debbie A Díaz Ortiz, independent midwife with the title of CPM, also MPH. Great-granddaughter of a Midwives of an isolated community. Co founder of the Latin American and Caribbean Network for Humane Childbirth in charge of the Caribbean and the midwives of far Communities. This year with 21 years of autonomous homebirth practice.