Maternal Health in Oaxaca, Mexico: The Role of the Midwife in Rural Medicine

Elaine Coldren, Teresa Gomez, Zachary Bay, Manuel Bramble, Praneet Korrapati, Krutika Lakhoo, & Amy Lu
Northwestern University Alliance for International Development (NU-AID) and Child Family Health International (CFHI) Introduction
According to the World Health Organization (WHO), the worldwide maternal mortality rate is unacceptably high. Approximately eight hundred women die each day from problems related to pregnancy and childbirth; ninety-nine percent of these deaths occur in developing countries (WHO, 2012). Mexico is a developing nation with a maternal mortality rate of 50 deaths per 100,000 births. As of 2010, the maternal mortality rate had decreased by thirty-six percent since 1990; however, mothers in the states of Chiapas, Oaxaca and Guerrero die in childbirth seventy percent more often than the national average (The Economist, 2010). This incongruity can be attributed to the rural landscape of Oaxaca, which makes it more difficult for the women to reach the hospital, and the communication difficulties due to the poor Spanish-speaking abilities of many indigenous mothers who often only speak native languages. Additionally, many indigenous women view birth as a natural process that does not require excessive medical attention such as a visit to a doctor, so they opt to see a partera instead. A partera is typically female which the mother and her spouse prefer due to the cultural taboo of a male doctor performing her gynecological examination (Layton, et al., 2007). According to The Economist, because of these logistical and cultural obstacles, investing in midwives and contraceptives is the solution to reducing the high maternal mortality rates in these states (The Economist, 2010). Based on this knowledge and discussions with local doctors and nurses about the needs of the patients in Oaxaca, the NU-AID group decided to invest time and funding in a medical workshop for parteras. A partera is often the first medical worker to see a pregnant woman, whether it is early on in the pregnancy or at the onset of labor. Therefore, equipping parteras, who can refer patients to hospitals, with information about prenatal care and signs of alarm during a pregnancy and childbirth would strengthen the first contact in the maternal health chain of command.

Methodology (cont.)
The group was also in contact with the local Child Family Health International (the groups not-for-profit partner organization) coordinator, Nick Penco, who provided the group with the list of workshop presentation topics two months prior to the program. These topics included: Risk Factors, Healthy Pregnancy, Complicated Pregnancy, Prenatal Care, Safe Childbirth, Complicated Childbirth, Attention to the Newborn, Postpartum Care, Maternal Nutrition, and Family Planning. The group met prior to arriving in Mexico to brainstorm and discuss creative ways to effectively present this material, keeping in mind that many of the parteras are illiterate and limited in their medical knowledge and resources. Presentations regarding prenatal care, family planning, and high-risk pregnancies and births would emphasize the importance of sending women to the nearest health centers for care that the parteras would not be equipped to provide. Shortly after, each student was assigned a topic and began preparing their respective presentation. Upon arrival in Mexico, the first two weeks were spent rotating through rural primary care clinics. These two weeks were important because not only did they allow for the group to acclimate to the cultural norms, but they also allowed the group to identify the specific needs of the rural communities. The third week was spent meeting with a local doctor, Isabel Saucedo, and a nurse, Teresa Carabante, to learn more about their experiences teaching and working with parteras. Two years ago, they ran a similar parteras training workshop and thus, had vital information to share with the group. Overall, the group gained a greater understanding of the current resources, beliefs, and traditions of the parteras that the group would be working with. Similar to Mrs. Vyhmeister, Dr. Saucedo and Nurse Carabante emphasized keeping the presentations simple and concise. They suggested that the group perform skits, play games, and ask questions. They also provided the group with all the necessary materials for the presentations, such as poster paper, baby dolls, toy placentas, measuring tapes, etc. After each meeting, the group edited the presentations according to the suggestions of the doctor and nurse. At the end of the third week, the group presented their work to each other and the nurse to ensure that the slideshows and skits were coherent and comprehensive.

Discussion
It is widely debated whether there should be a role for traditional parteras in modern medicine. In 2003, the Mexican government created Seguro Popular, a national public health insurance program. Through Seguro Popular, all prenatal, delivery, and postpartum care is free for all women in local clinics and hospitals with an aim to reduce the use of parteras, who do charge a fee for care (Gobierno Federal, Estados Unidos Mxico, 2010). While the use of parteras has decreased since 2003, many women still use them, especially in the more biodiverse and rural states of Mexico, such as Oaxaca (Paz, 2012). It is clear that midwifery is not going to be eliminated and it is in Mexicos best interest to equip parteras with the best tools and knowledge possible in order to reduce maternal mortality. The one-week workshop was very successful in providing useful, medical knowledge about pregnancy and childbirth. While there was no official evaluation of the workshop, it was clear that the parteras benefited from all training sessions when, at the end of the week, they performed activities that involved recalling everything that was taught to them. For example they performed an activity where they traced a silhouette of a woman on a poster and then drew signs and symptoms of a healthy or high-risk pregnancy on the silhouette. During the workshop, it was apparent that small group activities and skits were more beneficial than lectures; next year the facilitators would like to focus on using more didactic presentation techniques. Fortunately, meeting with the doctor and nurse beforehand to work on presentation style led improved the cultural sensitivity of the workshop and therefore it was well-received by the parteras. Based on the participation and the enthusiasm of the parteras the group is confident that they will use what they learned in their practice. In fact, two weeks after the workshop one of the parteras reported that she was putting all that she had learned to good use with her patients. Based on the success of the workshop, NU-AID plans on continuing its commitment to the parteras and the ongoing high rate of maternal mortality in Oaxaca. This will involve providing monetary support and the personnel to run the workshop every summer. One foreseeable limitation is that, due to the location of the workshop, the only parteras able to attend are those that can afford to travel from their homes to Puerto Escondido. To address this limitation, more funding would be required to either pay for parteras to come to Puerto Escondido or to pay for students and medical teams to travel to the rural communities and give the one-week workshop in order to reach more people.

Results Methodology
Preparing these educational workshops required determining an effective method of teaching local parteras about important issues related to pregnancy and childbirth in a simple and culturally sensitive manner. Two months before arriving in Mexico, the NU-AID group met with a local midwife to learn more about midwifery and some of the common cultural norms they would encounter during the training workshop. Heidi Vyhmeister, a midwife at Erie Family Health Center in Chicago, Illinois who works with a predominantly Spanish-speaking population, provided the group with valuable information about the cultural norms of indigenous populations in Oaxaca. She also gave the students tips to ensure that the group would be successful in its efforts to teach the local parteras about pregnancies and childbirth. . During the final week of our program, each of the seven students presented a series of important pregnancy and birth-related topics (i.e., risk factors, signs for alarm, etc), using a combination of Powerpoint slideshows, visual diagrams, and role-play to convey the information. Powerpoint slides were the primary media for delivering the information, as they allowed the group to present large descriptive pictures using a projector screen. The slideshows included minimal text so that all of the parteras, many of whom were illiterate, were able to understand the presented information. Given the potential for miscommunication due to language barriers, the group periodically requested that the parteras repeat the information back to the presenters to ensure that all of the information had been understood. The use of diagrams facilitated teaching some of the basic male and female anatomy, which often served as a foundation for the more complex pregnancy-related topics. Lastly, role play of both initial home visits and actual births was utilized to ensure that each partera had retained the information, could reproduce the steps, and could teach the skills to their peers. Each day consisted of 2-3 presentations, a review of the previous days material, short breaks, as well as designated time for the parteras to share their experiences regarding herbal remedies, unique cultural practices, or difficult deliveries. Additionally, over the course of the week several team-building exercises were incorporated into the schedule in order to promote trust and a sense of camaraderie. The most significant of these was the secret friend exercise, during which each member of the program (students, medical staff, and parteras) was matched with another member and instructed to send a friendly message or small gift daily, excluding the name of the sender. At the end of the week all secret friends were revealed, and each pair shared a hug and short conversation.

References
"Comisin Nacional De Proteccin Social En Salud - Seguro Popular." Gobierno Federal, Estados Unidos Mxico, 2010. Web. 17 Aug. 2012. <http://www.seguro-popular.gob.mx/>. "Maternal Health in Mexico: A Perilous Journey." The Economist. The Economist Newspaper, 24 June 2010. Web. 17 Aug. 2012. <http://www.economist.com/node/16439044>. Merrill, Tim L., and Ramn Mir. "Mexico - Health Care and Social Security." Mexico: A Country of Study. Washington: GPO for the Library of Congress, 1996. Web. 17 Aug. 2012. <http://countrystudies.us/mexico/63.htm>. Layton, Michael D., Beatriz Campillo Carrete, Ireri Ablanedo Terrazas, and Ana Mara Snchez Rodrguez. "Mexico Case Study: Civil Society and the Struggle to Reduce Maternal Mortality." Institute of Development Studies. Ford Foundation, Sept. 2007. Web. 17 Aug. 2012. <http://www.alternativasociales.org/sites/default/files/Mexico%20Case %20Study.pdf>. Paz, Alejandro. "Parteras; Tradicin Que Muere, Pero Deja Herencia." La Expresin. N.p., 11 July 2012. Web. 17 Aug. 2012. <http://laexpresion.info/inicio/?p=4527>. Country Cooperation Strategy at a glance: Mexico. World Health Organization. April, 2006. Web. 22 Aug. 2012. <http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_mex_en.pdf>

Acknowledgements
Thank you to Doctora Isabel Saucedo who gave us the idea for the midwife workshop and provided us with the information and personnel to make it successful. We would also like to thank Nurse Teresa Carabante who spent countless hours teaching us and helping us hone our presentations; her contribution to the workshop was invaluable. These two women taught us what it means to be dedicated to the health of a community. Without their passion and devotion, the workshop would not have been possible. Also, we would like to give a special thank you to Global Health International (GHI) for funding the program and making our amazing experience possible.