Any views expressed in this article are those of the author and not of Thomson Reuters Foundation.CARUARU, BRAZIL - Maria Fernanda da Silva, 39, is a traditional midwife from Caruaru, a city in the interior of Brazil's Northeast. She has been working as a midwife since she was 12. She started helping her mother, who is also a midwife, at age 9. "My mom called me her 'little assistant,'" da Silva says. She says she became more than an assistant at age 12 when a woman in her community needed help and her mother was out of town. "There was a woman in our community who would always give birth assisted by my mom," she says. "Oneday, she started delivering, and my mom was out of town. She did not want any other doctor to assist her delivery, so she begged [me] to do it for her." She says she resisted at first because she did not feel confident to deliver a baby before reaching her teenage years. Although she had watched her mother do it several times, it would be the first time she'd be doing it by herself. Since then, every once in a while, a neighbor asks her for help or a friend's friend calls her to schedule a delivery. Da Silva's mother, Josefa Carvalho, known here as Zefinha, has been a midwife for 44 years. She explains that when she started in 1967, there was not a single health clinic in her city. One time, she assisted a friend who was in labor because there was no one else around to help. From then on, she became the community's midwife. "Some people thought we knew everything!" Carvalho says, giggling. "I gained experience in assisting deliveries at the same pace I gained respect from our community." Da Silva says that in the beginning, she did not want to follow into her mother's profession. "It is not even considered a profession," she says. "The activity is actually very discriminated against. Most of the work we do in our community is unpaid." Da Silva says that sometimes, depending on how well-off families are, they provide financial compensation. But, as traditional midwives are more common in rural areas or indigenous communities, where most residents can't afford to pay midwives, midwives do not earn enough to make a living. Consequently, most midwives carry a double burden: They are midwives - usually for free - and something else - to earn money. Da Silva says this originally deterred her from following in her mother's footsteps. "I wanted to have a 'real' job," da Silva says. "I did not want to go through the sacrifices my mother did." But then she says she saw how important midwives are in her community. "But then when you see someone who needs you asking for help, it is impossible to refuse," she says. "And then I realized that being a midwife made me happy. Bringing someone to life is such a beautiful experience." Midwives say that they respect the mothers and babies they assist more than doctors because of the personalized care they can give outside of a hospital. But they say they receive little respect in turn from doctors and the government for the many communities they serve. Doctors say midwives lack the proper training to deliver babies. Meanwhile, various nongovernmental organizations, NGOs, are working to elevate the status of midwives and foster greater collaboration between them and public health officials. Traditional midwives play an important role in guaranteeing maternal and child health, mainly among the poor in Brazil's rural areas and indigenous communities in the forest. Reliable statistics are lacking because of insufficient registry of midwives, according to the Brazilian Ministry of Health. But, in general, the number of deliveries performed by traditional midwives is exponentially higher in the Northeast, one of Brazil's poorest regions, than in the South region, which has the highest level of human development. In Pernambuco, a state in the Northeast, there are about 870 traditional midwives, with about 75 percent of them active, according to the government's virtual registration of midwives from 2009 to 2011. Of this total, nearly 90 percent work in the state's rural areas. But this does not mean that traditional midwives have disappeared from urban areas. Danieli Siqueira is a social scientist from Recife, a city in the Northeast, and is an apprentice of a midwife. Her interest in being a midwife emerged when she got pregnant with her first son five years ago. She says that when she was a university student, she found an informative folder about traditional midwives. She found it interesting, so she kept the paper. Seven years later, when she got pregnant with her first son, she took the old folder out of the drawer and contacted the midwives. "When I got to know more about what they do and how they work, I fell in love with their universe," she says. Siqueira then decided not to deliver in a hospital but instead at home with a traditional midwife named Dona Prazeres, 73, who has 50 years of experience. After this experience, she says she decided to become further involved. Siqueira says the main difference between a delivery assisted by a doctor and a midwife is respect. "With a midwife, we have our emotional and physical integrity respected," she says. "Very frequently, in hospitals, doctors and nurses undertake unnecessary medical procedures that are invasive to the woman just because of commodity- or market-related reasons. They have so many people to assist, it is hard to give women the attention and care they need when giving birth." But she says that midwives value the mother and the baby. "In the eyes of a midwife, that baby is actually a baby, a new life coming to this world," she says. "In the eyes of a doctor, it is just one more 'NB' - abbreviation [for] 'newborn.'" Carvalho agrees. "When a pregnant woman in labor goes to a hospital, she does not know what expects her - whether she is going to be treated nicely or rudely, whether doctors will have time for her, where is she going to stay, whether she will have privacy or not," she says. "All of this creates anxiety and disturbs the natural flow of the labor." She says that, on the contrary, there is more trust during home deliveries by midwives. "In a residential delivery, the woman is expecting a friend who she trusts," she says. "She know[s] she will not suffer any kind of aggression." She says that most women in her community contact the midwife when they start suspecting they are pregnant. The midwife supports the women not only during labor, but also in the pre- and post-natal period as well. "After the child is born, not only [do] we keep checking if the breastfeeding and the baby's health is OK, but we are also called upon to help any family issues that arise," she says. She says midwives become such a part of the family that their duties sometimes even extend beyond the baby. "We give advice to the couple, we solve family fights [and] sometimes we even celebrate weddings," she says, giggling once again. Da Silva agrees with the different responsibilities a midwife has in her community. She jokes that not only are they midwives, but that they are also sheriffs, psychologists, judges, counselors and priests. Despite the important role traditional midwives play in their communities because of the respect they give to mothers, most public authorities and doctors give little - or no - respect to them. Da Silva says that midwives must depend on the sensitivity and political will of public officials in order to receive any assistance. For example, she says that in 1992, traditional midwives from her city organized themselves into an association, the Association of Traditional Midwives from Caruaru - of which she is currently the president. They were gaining visibility, raising awareness about the importance of humanizing health care services and working more closely with the government. But then, a new health minister was appointed. Da Silva says he was a doctor who did not support the work of midwives. He declared on television that traditional midwives didn't exist anymore, and that they were a product of the past. While he was in power, she says the government spent eight years without supporting midwives' activities. Lilian Sampaio, women's health manager in the Health Secretariat in Pernambuco state, agrees that traditional midwives face various challenges. She says that they need more recognition on the national scale because, with the way that it is now, they are fully dependent on the goodwill of the mayor or governor. "If they like midwives, if they don't have any prejudice against deliveries being performed out of the hospital, then they manage to pass on the financial resources they need," she says. "But it should not depend solely on their discretion." She also points out that midwives work in the best interest of the government, as they provide health care for thousands of women and children. But they do not earn a wage or any kind of financial incentives because the communities they serve can't afford to pay them, da Silva says. They also do not have the right to retirement benefits, so many of them can't support themselves when they reach an age when they can't work anymore. In addition, another important obstacle midwives face is medical rivalry. Da Silva says that many doctors see them not as partners working for a common goal, but rather as rivals who are trying to take over their space. Sampaio says that there is a lack of information among health students and professionals about the role of traditional midwives. "Very often, doctors and medicine students do not know what is the midwife doing there or how can she help," Sampaio says. Carvalho says doctors also don't realize that delivering at home can be safer than in a hospital. "Doctors keep saying that we have no hygiene because we attend births at the patient's home, but it is actually easier to get an infection in the hospital, as they put sick and pregnant people together," she says. Dr. Carlos Reinaldo Marques, an obstetrician at Amaury de Medeiros Integrated Health Center, says that the relationship between midwives and doctors is not positive. He recognizes the importance of midwives' work and agrees that the main obstacle midwives have to face is prejudice. But, he says there are some valid concerns about midwives' qualifications. He says that most of midwives' knowledge is cultural rather than scientific and that they lack the preparation to deal with more complex and risky situations. He also says that midwives' knowledge is transmitted through oral tradition and thus lacks uniformity. "There are some cases when there is a delay in the diagnosis by the midwife, and it can bring complications for the patient," he says. "When this happens, midwives tend to be very criticized by doctors." Meanwhile, various NGOs and the midwives themselves are working to raise awareness about the importance of midwives among doctors and the government in order to improve working conditions. Siqueira, after starting as a midwife apprentice, coordinates a group of pregnant women who hold weekly meetings in order to provide mutual support, orientations, and answers to their questions and anxieties as future mothers. Prazeres, the midwife who assisted Siqueira's delivery, is one midwife who attends the meetings. The group is called Gestar, which means gestating. Pregnant women can also find discussion forums about pregnancy and reproductive rights and various other information on the group's website. "To change the world, we have to start by changing the way we are born," the website reads. The Curumim Group, a feminist NGO that works with reproductive rights and women's health, leads Program Midwives, which was recently presented at a U.N. meeting in New York in as a successful program to improve health care services for women. The project's goal is to provide women with safe and humanized birth assistance while respecting geographical and ethnical differences. The initiative also aims to foster collaboration between traditional midwives and public health services as a strategy to reduce maternal and child mortality in Brazil. The project has been in place for more than two decades and has made advances in urging the government to implement home-based deliveries assisted by traditional midwives into its official strategies. The government has begun to provide training and materials, but this hasn't been consistent or widespread. The NGO has worked with more than 2,000 midwives and health professionals in 15 Brazilian states. Paula Viana, the coordinator of the Curumim Group, says the organization strives to link public health services and communities through a greater respect for midwives. "The work we develop with the midwives is fundamental for government actions in reproductive health to adhere to the communities where they are implemented because midwives tend to be important leaders in the eyes of their peers," she says. "Our goal is that midwives become - many already are - a connection between public health services and communities, mainly rural and indigenous ones."
Brazils traditional midwives lack support despite crucial services in rural areas
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