CASA ~ Midwifery Training in SAN MIGUEL ALLENDE, MexicoFeb 15, 2000Authors: By Jonathan FriedlandHealth care delivery Obstetrics Infant mortality MidwiferyAbstract:To Nadine Goodman, an American-born public-health specialist, Mrs. [Esperanza]Martinez -- known locally as Dona Esperanza -- is part of a tradition thatoffers Mexico a humane and cost-effective model for maternity care in thousandsof remote communities. In 1997, Ms. Goodman opened Mexico's first schoolof midwifery here in this town 180 miles northeast of Mexico City. Now,nine young women are getting more than three years of clinical trainingin delivering babies, combined with apprenticeships under parteras suchas 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 educationto operate her school, health authorities so far have refused to recognizeits graduates as professional midwives. Neither have they agreed to finda place for them in the country's overwhelmingly state-run health apparatusnor to designate a maternity hospital Ms. Goodman opened here in 1994 asan authorized training facility. The latter effectively prevents her graduatesfrom doing the mandatory social service Mexico requires of all medicalprofessionals.The conflict between Ms. Goodman and authorities such as Dr. [Carlos] Tenahighlights the disparity between what Mexico is and what it would liketo be. Officials believe they are providing good reproductive health careto 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, includingmobile ones that move between villages. The nation's infant- and maternal-mortalityrates 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 perwoman in 1965.
Copyright Dow Jones & Company Inc Feb 15, 2000Full Text:
SAN MIGUEL ALLENDE, Mexico -- Esperanza Martinez is a vanishing archetype.She is elderly and poor, and has only a primary-school education, but shehas 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 offersMexico a humane and cost-effective model for maternity care in thousandsof remote communities. In 1997, Ms. Goodman opened Mexico's first schoolof midwifery here in this town 180 miles northeast of Mexico City. Now,nine young women are getting more than three years of clinical trainingin delivering babies, combined with apprenticeships under parteras suchas 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 womenin their reproductive cycle," says Ms. Goodman, a 43-year-old ColumbiaUniversity graduate who settled here 20 years ago. "But the idea that good,low-cost service can be provided" by indigenous women "without a collegeeducation 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 preferto see die out. Though folk practitioners attend as many as a third ofthe nation's births, their ranks are thinning, and the medical establishmentsays there are enough doctors and nurses to replace the more than 18,000mostly rural midwives that remain.While Ms. Goodman has received a license from the secretary of educationto operate her school, health authorities so far have refused to recognizeits graduates as professional midwives. Neither have they agreed to finda place for them in the country's overwhelmingly state-run health apparatusnor to designate a maternity hospital Ms. Goodman opened here in 1994 asan authorized training facility. The latter effectively prevents her graduatesfrom doing the mandatory social service Mexico requires of all medicalprofessionals.Carlos Tena, the secretary of health of Guanajuato state, where boththe school and hospital are located, says that while he is all for givingexisting midwives the training necessary to do their jobs better, he seesno 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 aslong as she demands that parteras be recognized as professionals."The conflict between Ms. Goodman and authorities such as Dr. Tena highlightsthe disparity between what Mexico is and what it would like to be. Officialsbelieve they are providing good reproductive health care to the estimated23 million people who live outside the nation's cities. Over the past 40years, they have set up a vast web of rural clinics, including mobile onesthat move between villages. The nation's infant- and maternal-mortalityrates 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 perwoman in 1965.But dig a bit deeper and the picture isn't so rosy. In Mexico's poorestregions, women are still having lots of babies, and lots of those babiesare dying. In the country's 70,000 rural municipalities, the birth ratestill stands at five per woman, and infant- and maternal-mortality ratesare well above the national average. Moreover, while Mexico graduates plentyof doctors and nurses, few of them want to live in rural areas, even whenrequired 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 NationalPopulation Council. "In many villages, we are where we were nationally30 years ago."The village of Jamaica, about 40 miles from San Miguel, is typical insome respects. Late one afternoon, knots of women sit beneath mesquitetrees, their children playing in the dusty streets. As in many poorer ruralareas, there are few men in residence; most work in the U.S. or in factoriesacross the mountains in Guanajuato's industrial cities. The men come backonce in a while, often impregnating their wives before returning to work.The result, says local congresswoman Maria Luisa Mitcher, is "a clear feminizationof rural poverty."That's one factor that has influenced Ms. Goodman's vision. Armed withmaster's degrees in public health and social work, she arrived in thisarid region in 1981. Her original intent was simply to learn Spanish, butshe soon began offering sex education and family-planning information tolocal youth. Three years later, she and her husband, Alejandro, a Mexican,set up a nonprofit organization called Centro para los Adolescentes deSan Miguel de Allende, or CASA, backed by a $3,000 grant from the InternationalPlanned Parenthood Federation.Since then, CASA has grown to include a variety of reproductive- andenvironmental-education programs, outpatient medical services, a maternityhospital, daycare centers and the midwifery school. Over the years, Ms.Goodman has raised more than $15 million to support CASA's programs fromdonors including the Ford Foundation, the David and Lucile Packard Foundationand the Dutch chapter of Save the Children.Sitting in the courtyard of the midwifery school, an imposing stonestructure that resembles a colonial hacienda, Ms. Goodman says traditionalparteras first approached CASA in the mid-1980s, seeking information onfamily planning, as well as a stable source of contraceptives for the womenin 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 understoodsome fundamental things: that women have the right to control their ownfertility 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 hospitalwhere both her mother and father worked, the parteras represented a practicalalternative worth building on.That was especially so, from Ms. Goodman's point of view, given oneof the more disturbing trends in Mexican birthing practices: the widespreaduse of Caesarean sections. An estimated 40% of Mexican babies are deliveredby Caesarean, a C-section rate second only to that of Brazil.Doctors here, an overwhelming majority of which are male, generallyprefer C-sections because they can be scheduled and because insurers reimbursemore for the surgical procedure than for a natural delivery. Many Mexicanwomen also prefer them because they think the pain of recovering from aCaesarean is less than the pain of a vaginal birth. And, until the mid-1990s,the Mexican government encouraged Caesareans as a tool for reducing infantmortality. Alejandra Bermudez, a Colombian obstetrician who works at anup-market Mexico City hospital, says that by the time many Mexican doctorshave completed their social service in government clinics, "they've forgottenhow to deliver a baby naturally."The CASA maternity hospital that Ms. Goodman opened in 1994 was thefirst in Mexico to be staffed mainly by midwives. A spotless, airy facilitywith a portrait of the 17th-century Mexican proto-feminist poet and scientistSor Juana Ines de la Cruz gracing its entry, the hospital has since handled2,800 births. Only one woman has died in childbirth there, the hospital'sinfant-mortality rate is below that of equivalent facilities, and the C-sectionrate is a fraction of the national average.Still, the CASA hospital has raised hackles. In May 1998, the Guanajuatohealth secretariat refused to renew a sanitary license the facility neededto continue operating. Ms. Goodman says inspectors told her they were closingthe hospital on the grounds that Mexican law provides for midwives to workonly in their communities, not in a medical facility. Dr. Tena, the Guanajuatohealth secretary, says the permit was pulled "because there was no doctorin charge," an allegation Ms. Goodman denies. The CASA midwives gatheredmore than 10,000 signatures from nearby communities and delivered them,along with 200 letters of support from donors, to the private secretaryof then-Gov. Vicente Fox, now the presidential candidate of the center-rightNational Action Party. The license was promptly renewed.But more than the hospital, it has been the midwifery school, and particularlyMs. 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 explainingtheir opposition, private doctors are less so. They say it is an insultto the rural poor to offer anything less than the kind of care availablein a big-city hospital. And they label Ms. Goodman a well-meaning, butmisguided, foreign feminist.Roberto Uribe, a professor at the National Autonomous University ofMexico and an officer of the National Federation of Gynecologists and Obstetricians,says the idea of reviving the partera, even with clinical training, "isa tremendous step backward.""It doesn't matter if the parteras all die off," Dr. Uribe says. "Thereal 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 SanMiguel Allende. The midwife, who has one tooth and is a little stiff fromarthritis, says she serves about 500 families in seven communities. Sheadds that while San Miguel Allende and its hospital are only about an houraway from her village by bus, most women in the vicinity can't afford sucha 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 isno guarantee her school will be a success. Several of the students, whoare picked from villages across Mexico and given scholarships to defraymost of their costs, have dropped out. Some were too lonely living awayfrom their families; others found the studies too demanding. And the battleswith 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 andfollow in her mother's footsteps. Sitting by the side of a teenager nervouslygoing into labor at the CASA hospital, she quietly offers tips on breathingand pain control. Fifteen hours later, she'll still be with the motheras her baby boy is born. "This," says Ms. Velasco, "is about the most beautifulthing in the world."(See related letter: "Letters to the Editor: At Times, Doing Good IsMerely Interference" -- WSJ March 2, 2000)Credit: Staff Reporter of The Wall Street Journal