Midwives in training at CASA fill a gap

SAN MIGUEL DE ALLENDE, Mexico (WOMENSENEWS)–As the United Nations puts new emphasis on midwifery as a way of combating maternal and child mortality, a small school in Mexico’s central highlands could offer an example that leads the way.

Here in San Miguel, a central Mexican city of 100,000, the Center for Adolescents of San Miguel de Allende–known as CASA–has been conferring the country’s only professional midwifery degree since 1999.

Since opening in 1996 the private school has been training mainly rural women in a three-year program plus one-year residency. Special features include the involvement of traditional midwives as teachers, outreach to indigenous students and academic rigor even as it accepts students who may not have finished high school.

While CASA is singular in its attempt to professionalize the practice of midwifery, it joins other methods of bringing midwives back into the mainstream in Latin America after decades of the medicalization of childbirth.

The Mexican Ministry of Health’s Department of Traditional Medicine and Intercultural Development, for instance, brings together traditional midwives and doctors so they can learn from one another, says its director, Dr. Alejandro Almaguers.

But the health ministry does not train new midwives, says the department’s deputy director, Dr. Hernan Jose Garcia. Traditional midwives’ expertise and community connections are enough to complement doctors’ medical knowledge, he says.

The obstetrical nursing program of the country’s leading university, the National Autonomous University of Mexico, and the National Institute of Public Health teach health practitioners to assist in delivery. And various nongovernmental organizations and other groups run midwife training programs. But only CASA confers midwifery degrees.

Daughters of Traditional Midwifery

Nadine Goodman, a U.S. expatriate when she founded CASA, describes the students as primarily indigenous women with little money or education. "The majority are daughters of traditional midwives, or their grandma was a midwife."

Two exceptions to that are Maria Elena Pascual, 22, and Gloria Gaspar, 22, from the southern state of Chiapas.

A midwife teaches about traditional herbs.

Both say they learned about the program from a doctor and came to CASA because they realized that many women die in labor due to lack of access to medical services in remote areas.

Gaspar is from a small community just outside the municipality of Trinitaria, about an hour and a half from Guatemala. In addition to Spanish she speaks Canjobal, a Mayan dialect. Pascual is also from Trinitaria but from a different outlying community.

In a society that often keeps families close, particularly young women, they are about 600 miles from home.

Throughout their training, students spend four weeks at a time working and living with midwives in the countryside as part of their coursework. Last winter the two women served in small communities outside Trinitaria.

"We learned and observed and did a lot of things that we had never before done in our lives," said Pascual. "I didn’t know my people. I would see (midwives), but I hadn’t really lived with them. But on this trip I lived and worked with them in their communities."

Both students said that traditional midwives welcomed them, offered support and were eager to learn from the two students, even asking for training. "They learned from us, and we learned from them," said Gaspar, who said they taught her about using plants, herbs and massage during labor, among other practices.

Payment in Trade

Both women are aware that when they start practicing their only payment may be in milk and eggs.

In preparation for that, Gaspar would like to save money from what she earns during her one-year residency in a hospital or clinic. Then she hopes to return home and rent a room in which to see patients, conduct community outreach and connect with traditional midwives.

"There’s no specific place to practice, people don’t know you, and I think that first one has to do major outreach to let people know you’re there," Pascual says.

Goodman, now an adviser to CASA, says she began the program to meet demand among midwives for more education.

She came to Mexico in 1981 to learn Spanish and says she ended up staying 27 years. With a psychology degree from Pitzer College in California and two master’s degrees from Columbia University, one in social work and one in public health, she developed her expertise in both midwifery and Mexico’s needs in that area.

Goodman wants to expand the school so students can be closer to home and the populations they will serve. Midwives and health officials have requested campuses in San Luis Potosi state, Chiapas and Guatemala, Goodman says. The Guatemalan government has committed $1.7 million to train 140 new midwives, and in Mexico the Chiapas state government has allocated funds to train 20 to 30 new midwives in the mountain town of San Cristobal de las Casas.

With its round-the-clock demands, Goodman says, midwifery is a calling. "If you talk to midwives in Chiapas, they have to have a dream to tell them to be a midwife."

CASA’s efforts are exactly the type of initiative that global maternal health experts have in mind when they talk about using midwives to connect women with medical care in hard-to-reach communities.

U.N. Renews Maternal Initiative

In September, the U.N. General Assembly announced it would renew efforts to meet two of the eight U.N. millennium development goals, ambitious targets to end world poverty. Goal No. 4 vows to cut child mortality by two-thirds. Goal No. 5 is reducing maternal deaths by 75 percent by 2015. The global shortage of midwives is estimated at 334,000.

A task force formed for those efforts will seek financing to strengthen health care systems and fund health workers. The task force will report its findings at a 2009 global summit in Italy.

And a U.N. event called the Commitment to Progress for Mothers, Newborns and Children brought together representatives from over 100 countries to promote midwifery and implement women’s health measures.

Health advocates familiar with both CASA and the worldwide need for midwives say the school is at the vanguard of addressing the shortage.

Arletty Pinel, until recently a special maternal health advisor at the U.N. Population Fund, is now establishing a health center in Panama. She says CASA embodies an innovative approach.

"It is a solid vocational-level training that is able to take these girls who otherwise wouldn’t have much chance of education, period, to acquire skills of something that is very noble and something that is very needed, which is the holistic attention of the woman through the process of pregnancy, delivery and post-birth," says Pinel. "It’s a small initiative but nevertheless a very significant one."

Corey O’Hara, a senior manager at the New York-based Clinton Global Initiative, says the link between CASA-trained midwives and normal birth weight is striking.

"I would say that one of the things that has been the most impressive to those of us familiar with infant health and mortality is low birth weight," he says. "Their midwifery program is one of the few instances where it’s been very clear that there’s a correlation between decreased incidence of low birth weight and the presence of a midwife."

O’Hara adds, "Everywhere in the world there’s a need for programs like this."

Theresa Braine freelanced in Mexico City for more than seven years, covering women’s issues, public health, breaking news and other topics. She is now based in New York.

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