Latin America: another story

A newborn boy rests on his mother's stomach. Midwives   believe mothers should experience childbirth as a   "natural process," without undue medical intervention.   (Photo ©Armando Waak - PAHO/WHO)

Such conditions, says Dr. Virginia Camacho of the Pan American Health Organization (PAHO), put the issue of midwives into a different perspective. The problem in many poor areas, she says, is that pregnant women lack access at the local level to essential, and particularly emergency, obstetrical care. Traditional midwives, she notes, are not competent to treat crises such as preeclamsia, infections, and hemorrhage.

Dr. Camacho heads PAHO's Regional Initiative for Reduction in Maternal Mortality, which is working to improve the profile of maternal and infant health in the region. In the late 1990s, infant mortality in Latin Amer-ica and the Caribbean as a whole stood at 35.5 per 1,000 live births, and maternal mortality at 190 per 100,000 live births. While these rates compare favorably with other developing regions, they are still far behind North America, where infant mortality is 7 per 1,000 live births and maternal mortality 11 per 100,000 births.

To improve this picture, PAHO, UNICEF, and others are supporting initiatives to increase patient choice of and access to medical facilities. Working with countries' ministries of health, these programs aim to increase the use of comprehensive, quality maternal health services. These include community birthing centers and maternity waiting homes where women can get care and deliver if they have no problems, but which can recognize warning signs and refer patients to more specialized care when necessary.

While emphasizing basic care and improved access, these programs are also attempting to incorporate many of the concerns that midwives and other proponents of "woman-centered birth" have brought to the fore. "The culture of birth is changing," acknowledges Dr. Camacho. "We are beginning to assess women's and their families' needs. We are finally listening to the community and learning to link culture to health services."

As for midwives as a "childbirth alternative," Dr. Camacho points out that only a handful of Latin American countries currently have professional programs in midwifery with training and licensing to provide services ranging from family planning to prenatal care, delivery, and postpartum follow-up. However, many countries offer training that approaches the U.S. nurse-midwife model, that is, university-educated nurses who receive supplemental training in obstetrics. Supporting this model, Dr. Camacho observes, "could be an alternative strategy for Latin America to improve competencies and skills in the kind of obstetric care that we know is effective in reducing maternal mortality, while also being cost effective and woman-centered."

A nurse briefs parents-to-be on newborn care at a hospital in Taguatinga, D.F., Brazil. PAHO programs aim at increasing choice in maternity health services. (Photo ©Armando Waak - PAHO/WHO)

Meanwhile, others are working to improve the skills and knowledge of traditional midwives, who outnumber professional midwives in the region. The Active Center for Human Integration (CAIS), established 10 years ago in Olinda, Pernambuco, Brazil, coordinates a National Network of Traditional Midwives from its offices in one of the poorest regions of the country. To date, the network has signed up nearly 7,000 midwives as members and has provided training to some 3,500.

"We work to provide training, legalization, and inclusion of midwives in the official health system," says CAIS's childbirth coordinator, Ms. Dayse Reis. "Midwives are important allies of community health programs and could be much better utilized in the traditional health system." Brazil's Ministry of Health estimates there are some 60,000 traditional midwives in that country, though Ms. Reis believes that may be an underestimate: "Many midwives work on the banks of rivers, at the foot of mountains, far from any system of accreditation or control."

Ms. Reis concedes that most traditional midwives are strictly empirical, have little notion of anatomy, and are often illiterate. Therefore, she says, training should be designed to fill in those gaps and to ensure that traditional midwives are capable of referring patients to emergency care when necessary. "An experienced midwife can tell if there are problems well before the birth," says Ms. Reis. "Part of CAIS's work is to train them in areas such as first aid."

Midwives' advocates say it is important that training programs such as these be conducted in the women's mother tongue and by other women, and that midwives be trained within the referral system rather than in isolation.

But while traditional midwives-and their patients-can without doubt benefit from outside training, Prof. Walsh and other nurse-midwives caution that transferring technology and obstetric practices from one culture to another can have unintended negative consequences. In the United States, Prof. Walsh says, "We have not done a good job of examining the appropriate use of technology, and as a result we have inappropriately exported obstetrical technol-ogy that even here has not proven to be effective."

She recalls the experience of a small clinic in San Lucas Tolimán, Guatemala, which received an electronic fetal monitor to use during patients' labor-despite the fact that the monitor's usefulness is being questioned in the United States. "We simply don't know when it makes sense," agrees another nurse-midwife, "and to send our standards to other countries is misguided."

Prof. Walsh sees a more serious problem. "Where we often run into trouble is when we assume that providing skills training will improve care provision, when in fact, it may increase problems with morbidity and mortality." As an example, she points to the promotion of cervical examination as a way of assessing the progress of labor. "Traditional midwives don't have access to sterile gloves and so may increase the incidence of infection by using this practice," she observes.

For Ms. Williams of the American College of Nurse Midwives, what should be promoted across cultures is a "model of care that seeks to empower women and results in a childbirth experience that re-inforces a woman's ability to mother and a family's identity." Dr. Kenneth Bell, of Kaiser Permanente, has called it "gentling the art of obstetrics."

But clearly, achieving a balance between appropriate interventions for reducing maternal and infant mortality, and childbirth practices that are humane and focused on women's experience, calls for further development of effective models, particularly in Latin America. "Childbirth is a noble act and we don't give it enough respect," says PAHO's Dr. Camacho. "We need to humanize the birth experience, but we also need to provide quality care."

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