CASA ~ Midwifery Training in SAN MIGUEL ALLENDE, Mexico

Feb 15, 2000
 
Authors:                  By Jonathan Friedland
 
Health care delivery   Obstetrics   Infant mortality Midwifery
 
Abstract:
 
To Nadine Goodman, an American-born public-health specialist, Mrs. [Esperanza]
Martinez -- known locally as Dona Esperanza -- is part of a tradition that
offers Mexico a humane and cost-effective model for maternity care in thousands
of remote communities. In 1997, Ms. Goodman opened Mexico's first school
of midwifery here in this town 180 miles northeast of Mexico City. Now,
nine young women are getting more than three years of clinical training
in delivering babies, combined with apprenticeships under parteras such
as Mrs. Martinez who work with little more than scissors and a bag of herbs.
The school expects to graduate its first class this fall.
While Ms. Goodman has received a license from the secretary of education
to operate her school, health authorities so far have refused to recognize
its graduates as professional midwives. Neither have they agreed to find
a place for them in the country's overwhelmingly state-run health apparatus
nor to designate a maternity hospital Ms. Goodman opened here in 1994 as
an authorized training facility. The latter effectively prevents her graduates
from doing the mandatory social service Mexico requires of all medical
professionals.
 
The conflict between Ms. Goodman and authorities such as Dr. [Carlos] Tena
highlights the disparity between what Mexico is and what it would like
to be. Officials believe they are providing good reproductive health care
to the estimated 23 million people who live outside the nation's cities.
Over the past 40 years, they have set up a vast web of rural clinics, including
mobile ones that move between villages. The nation's infant- and maternal-mortality
rates have dropped sharply. And the use of contraceptives has soared nationally,
cutting Mexico's birth rate to 2.4 births per woman today from 7.3 per
woman in 1965.
Copyright Dow Jones & Company Inc Feb 15, 2000
 
Full Text:

SAN MIGUEL ALLENDE, Mexico -- Esperanza Martinez is a vanishing archetype.

She is elderly and poor, and has only a primary-school education, but she
has skill enough to have coaxed more than 1,500 babies into the world.
 
To Nadine Goodman, an American-born public-health specialist, Mrs. Martinez
-- known locally as Dona Esperanza -- is part of a tradition that offers
Mexico a humane and cost-effective model for maternity care in thousands
of remote communities. In 1997, Ms. Goodman opened Mexico's first school
of midwifery here in this town 180 miles northeast of Mexico City. Now,
nine young women are getting more than three years of clinical training
in delivering babies, combined with apprenticeships under parteras such
as Mrs. Martinez who work with little more than scissors and a bag of herbs.
The school expects to graduate its first class this fall.
 
"The professional midwife is the best option for accompanying women
in their reproductive cycle," says Ms. Goodman, a 43-year-old Columbia
University graduate who settled here 20 years ago. "But the idea that good,
low-cost service can be provided" by indigenous women "without a college
education really shakes things up here."
 
In fact, midwifery is a tradition that certain Mexican government officials,
as well as the country's leading obstetrics organization, would prefer
to see die out. Though folk practitioners attend as many as a third of
the nation's births, their ranks are thinning, and the medical establishment
says there are enough doctors and nurses to replace the more than 18,000
mostly rural midwives that remain.
 
While Ms. Goodman has received a license from the secretary of education
to operate her school, health authorities so far have refused to recognize
its graduates as professional midwives. Neither have they agreed to find
a place for them in the country's overwhelmingly state-run health apparatus
nor to designate a maternity hospital Ms. Goodman opened here in 1994 as
an authorized training facility. The latter effectively prevents her graduates
from doing the mandatory social service Mexico requires of all medical
professionals.
 
Carlos Tena, the secretary of health of Guanajuato state, where both
the school and hospital are located, says that while he is all for giving
existing midwives the training necessary to do their jobs better, he sees
no point in creating new ones. "I don't think Nadine's vision is workable,"
says Dr. Tena, a cardiologist. "And I will continue fighting with her as
long as she demands that parteras be recognized as professionals."
 
The conflict between Ms. Goodman and authorities such as Dr. Tena highlights
the disparity between what Mexico is and what it would like to be. Officials
believe they are providing good reproductive health care to the estimated
23 million people who live outside the nation's cities. Over the past 40
years, they have set up a vast web of rural clinics, including mobile ones
that move between villages. The nation's infant- and maternal-mortality
rates have dropped sharply. And the use of contraceptives has soared nationally,
cutting Mexico's birth rate to 2.4 births per woman today from 7.3 per
woman in 1965.
 
But dig a bit deeper and the picture isn't so rosy. In Mexico's poorest
regions, women are still having lots of babies, and lots of those babies
are dying. In the country's 70,000 rural municipalities, the birth rate
still stands at five per woman, and infant- and maternal-mortality rates
are well above the national average. Moreover, while Mexico graduates plenty
of doctors and nurses, few of them want to live in rural areas, even when
required to do so as part of their social-service obligations. As a result,
many village clinics are left unattended for months on end.
 
"The coverage of public health service has some very serious limitations,"
says Rodolfo Tuiran, a demographer who heads the government's National
Population Council. "In many villages, we are where we were nationally
30 years ago."
 
The village of Jamaica, about 40 miles from San Miguel, is typical in
some respects. Late one afternoon, knots of women sit beneath mesquite
trees, their children playing in the dusty streets. As in many poorer rural
areas, there are few men in residence; most work in the U.S. or in factories
across the mountains in Guanajuato's industrial cities. The men come back
once in a while, often impregnating their wives before returning to work.
The result, says local congresswoman Maria Luisa Mitcher, is "a clear feminization
of rural poverty."
 
That's one factor that has influenced Ms. Goodman's vision. Armed with
master's degrees in public health and social work, she arrived in this
arid region in 1981. Her original intent was simply to learn Spanish, but
she soon began offering sex education and family-planning information to
local youth. Three years later, she and her husband, Alejandro, a Mexican,
set up a nonprofit organization called Centro para los Adolescentes de
San Miguel de Allende, or CASA, backed by a $3,000 grant from the International
Planned Parenthood Federation.
 
Since then, CASA has grown to include a variety of reproductive- and
environmental-education programs, outpatient medical services, a maternity
hospital, daycare centers and the midwifery school. Over the years, Ms.
Goodman has raised more than $15 million to support CASA's programs from
donors including the Ford Foundation, the David and Lucile Packard Foundation
and the Dutch chapter of Save the Children.
 
Sitting in the courtyard of the midwifery school, an imposing stone
structure that resembles a colonial hacienda, Ms. Goodman says traditional
parteras first approached CASA in the mid-1980s, seeking information on
family planning, as well as a stable source of contraceptives for the women
in their communities. The parteras, she recalls, were generally elderly,
and most hadn't made it through primary school. Many were illiterate. But,
she adds, "they were devoted to their communities. And they understood
some fundamental things: that women have the right to control their own
fertility and that the first right of a child is to be planned and welcomed."
 
To Ms. Goodman, whose adolescent bible was the feminist health manual
"Our Bodies, Our Selves," and who grew up around the New York hospital
where both her mother and father worked, the parteras represented a practical
alternative worth building on.
 
That was especially so, from Ms. Goodman's point of view, given one
of the more disturbing trends in Mexican birthing practices: the widespread
use of Caesarean sections. An estimated 40% of Mexican babies are delivered
by Caesarean, a C-section rate second only to that of Brazil.
 
Doctors here, an overwhelming majority of which are male, generally
prefer C-sections because they can be scheduled and because insurers reimburse
more for the surgical procedure than for a natural delivery. Many Mexican
women also prefer them because they think the pain of recovering from a
Caesarean is less than the pain of a vaginal birth. And, until the mid-1990s,
the Mexican government encouraged Caesareans as a tool for reducing infant
mortality. Alejandra Bermudez, a Colombian obstetrician who works at an
up-market Mexico City hospital, says that by the time many Mexican doctors
have completed their social service in government clinics, "they've forgotten
how to deliver a baby naturally."
 
The CASA maternity hospital that Ms. Goodman opened in 1994 was the
first in Mexico to be staffed mainly by midwives. A spotless, airy facility
with a portrait of the 17th-century Mexican proto-feminist poet and scientist
Sor Juana Ines de la Cruz gracing its entry, the hospital has since handled
2,800 births. Only one woman has died in childbirth there, the hospital's
infant-mortality rate is below that of equivalent facilities, and the C-section
rate is a fraction of the national average.
 
Still, the CASA hospital has raised hackles. In May 1998, the Guanajuato
health secretariat refused to renew a sanitary license the facility needed
to continue operating. Ms. Goodman says inspectors told her they were closing
the hospital on the grounds that Mexican law provides for midwives to work
only in their communities, not in a medical facility. Dr. Tena, the Guanajuato
health secretary, says the permit was pulled "because there was no doctor
in charge," an allegation Ms. Goodman denies. The CASA midwives gathered
more than 10,000 signatures from nearby communities and delivered them,
along with 200 letters of support from donors, to the private secretary
of then-Gov. Vicente Fox, now the presidential candidate of the center-right
National Action Party. The license was promptly renewed.
 
But more than the hospital, it has been the midwifery school, and particularly
Ms. Goodman's insistence that midwives be recognized as professionals,
that has caused conflict with the state and the medical establishment.
While functionaries, including Dr. Tena, are generally tactful in explaining
their opposition, private doctors are less so. They say it is an insult
to the rural poor to offer anything less than the kind of care available
in a big-city hospital. And they label Ms. Goodman a well-meaning, but
misguided, foreign feminist.
 
Roberto Uribe, a professor at the National Autonomous University of
Mexico and an officer of the National Federation of Gynecologists and Obstetricians,
says the idea of reviving the partera, even with clinical training, "is
a tremendous step backward."
 
 "It doesn't matter if the parteras all die off," Dr. Uribe says. "The
real issue is: How do you get rural women to the hospital on time?"
 
That perspective amuses Mrs. Martinez, the midwife, and her apprentice,
Rosa Maria Arriaga, a 26-year-old unwed mother from a poor section of San
Miguel Allende. The midwife, who has one tooth and is a little stiff from
arthritis, says she serves about 500 families in seven communities. She
adds that while San Miguel Allende and its hospital are only about an hour
away from her village by bus, most women in the vicinity can't afford such
a trip. "I haven't lost a mother in 16 years," Mrs. Martinez says. Sometimes,
she adds, she gets paid for her services in eggs.
 
Still, even if Ms. Goodman does get the permits she needs, there is
no guarantee her school will be a success. Several of the students, who
are picked from villages across Mexico and given scholarships to defray
most of their costs, have dropped out. Some were too lonely living away
from their families; others found the studies too demanding. And the battles
with authorities haven't helped morale, Ms. Goodman says.
 
Yet the students who have stuck it out seem determined. Cepatli Velasco,
22, came from a village in Oaxaca state to take the midwife course and
follow in her mother's footsteps. Sitting by the side of a teenager nervously
going into labor at the CASA hospital, she quietly offers tips on breathing
and pain control. Fifteen hours later, she'll still be with the mother
as her baby boy is born. "This," says Ms. Velasco, "is about the most beautiful
thing in the world."
 
(See related letter: "Letters to the Editor: At Times, Doing Good Is
Merely Interference" -- WSJ March 2, 2000)
 
 Credit: Staff Reporter of The Wall Street Journal