In the villages of Tabatinga, Amazonas, Ticuna midwives workaccording to ancestral traditions, honing their skills generation aftergeneration. However, they remain unrecognised by the state.
Translated for LAB by Tom Gatehouse. You can read the original (in Portuguese) here. This is the first in what we hope will be a series of articles by LAB partner Agência Pública, São Paulo.
“Three of my children died here,” comments a taciturn LourdesAraújo Firmino. It was morning and we had just passed the military hospital,located on the main road running through the city of Tabatinga, in the state ofAmazonas in northern Brazil.
Lourdes’ first two children had been suffering fromcomplications and died after birth. However, her third, Maria, was healthy atthe end of gestation, despite the military doctors having warned her thepregnancy was risky, as the 36-year-old Lourdes suffered from obesity anddiabetes. It was Maria’s death which has had the biggest impact on her life.
Lourdes, of the Ticuna people, is an indigenous midwife byprofession. On the day her waters broke, she decided she wanted a naturalbirth. But the doctors wouldn’t listen to her. “It was too early to pull herout,” she says. “I told them that, but they ignored me.”
At the time, the early 2000s, it wasn’t possible for anyoneto accompany women going into labour in public hospitals. Despite her husband’sprotests, he was prevented from entering the operating theatre to be at hiswife’s side. He was only allowed to see her once Maria’s death had beenconfirmed.
Lourdes, now 52, shows me the photos she took of Maria afterbirth. There are lacerations on her arms and neck. “Look at how badly hurt shewas. They were impatient, they pulled her too hard,” she says.
A study by the Fundação Perseu Abramo, a Brazilianthinktank, has found that some form of abuse – whether physical or verbal – occursin one out of every four births in Brazil.
Modern techniques have increased the ability ofobstetricians to decide how and when birth will occur, including the use ofoxytocin; the decision to place the woman on a bed, restricting her movement;and the surgical incision known as an episiotomy.
This is all completely antithetical to the principles bywhich Lourdes practises her profession. “A good birth must be done by the womanherself, in her own time. She has to discover herself; you can’t forceanything. Our job is just to stay with her and look after her on this journey,”she says.
Lack of recognition
In 2018, according to the local branch of the Special Indigenous Sanitary District (DSEI, in the Portuguese acronym), half of the 82 babies born in Umariacu, one of the Ticuna villages located around Tabatinga, were delivered by local midwives. However, the government doesn’t recognise this activity and officially the women are considered “unemployed”.
This traditional midwifery stands in stark contrast to thelogic of the Brazilian healthcare system. Fifty-six per cent of all births inthe country in 2017 (the last year for which data is available) were carriedout via caesarean section. In the private hospitals of São Paulo, Brazil’srichest city, eight out of every ten babies come into the world via caesarean.And with the highest rates of birth via c-section worldwide, Brazil is at the forefrontof a troubling global phenomenon.
Global use of caesarean has doubled in the 21stcentury, despite the World Health Organisation (WHO) urging countries to ensurethat their healthcare systems increase rates of vagin*l birth. According to theresearch, in no more than 15% of cases is there a genuine need for thissurgical intervention.
Despite this, one in every three babies born worldwide is stilldelivered by a midwife, according to the United Nations Population Fund. Andit’s the countries which have effectively managed to combine tradition andmodernity which obtain the best results.
In England, a quarter of low-risk births take place at home,supervised by the NHS. In the Netherlands, the use of anaesthetics is not encouraged,and most babies are delivered by midwives rather than doctors. As a result, 65%of births take place at home, while the rate of caesarean is less than 15%.
In Brazil, midwives are often ignored by other healthcareprofessionals, even when the system tries to accommodate them. In a master’sthesis at the Fundação Oswaldo Cruz (Fiocruz-AM) entitled “Care offered bytraditional midwives”, Ticiane Melo de Souza looked into this relationship, findingthat some professionals tend to discriminate against midwives due to a rejectionof their worldview.
This means that midwives’ knowledge – not only of childbirth,but also of pre- and post-natal care – goes to waste.
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From generation to generation
In general, the Ticuna midwives speak little Portuguese,live in modest houses and spend their time caring for expectant mothers, whosometimes offer them food as a form of showing their gratitude. These women,most of whom are elderly and illiterate, are the ones who oversee the moment inwhich – as they see it – the girl dies so the woman can be born, as a mother.
The midwives learn their trade without any formal training. Theymight become involved through their family, but their licence to practise is grantedby the wider community, which will call for them if any problem arises. Some ofthem talk of a “talent” for being a midwife. All of them talk of tradition. Undoubtedly,they are practising one of humanity’s oldest professions.
Arminda Gomes says midwifery has been in her family forgenerations. While she started out assisting expectant mothers on the Peruvianside of the Amazon River, the first baby she delivered was her own. She wasjust 16 and she was alone.
“I was standing up and I held onto the hammock. I didn’tknow what to do or how to do it. I felt really alone,” she says. “It’s a riteof passage for the woman, which is why we [the midwives] have to be with her,to guide her.”
Nazaré Gralindo credits her aunt for the instruction shereceived. She has had 11 children, all of whom were born at home. “Always withthe help of the midwives,” she says. “At the hospital they treat you badly,they pull the baby. They use only the strength of the doctor and the woman isignored.”
Another Ticuna woman, Páscoa Farias, participated in herfirst birth at 13, which was overseen by her mother. “It takes a bit of gettingused to. There’s a lot of blood, crying. Men generally can’t handle it. You’vegot to be patient and kind. A birth can last seven, nine, eleven hours,” shesays.
Lourdes, who is the leader of the Umariacu midwives, wasintroduced to the trade by her great-aunt. At first her role was just to watchand learn, but when she was 19, her sister-in-law went into labour and with nomore experienced midwife available, she was forced to act.
Although the older women in her life had given her someinstruction, Lourdes recalls that on that day she acted largely on instinct.“The baby’s head had come out, it just needed to wiggle a little further for meto get a hold on its shoulder. At the time I didn’t know this, but later Irealised that you might be helping at a moment of life and death. Making surethe women aren’t alone is the reason I like this work,” she says.
For Lourdes, caesarean contradicts the notion that givingbirth is about patience and contact with our animal nature, principles that shemaintains in her work. “[In hospital] The woman is there on her back waitingfor someone to tell her what to do and how to do it. The man, if he’s there,often can’t handle being there for the birth, while the doctor just wants toget it over with because he’s got other work to do.”
Childbirth as a community ritual
Even when they know a birth will be complicated, the Ticunasprefer to place their trust in the older women. Whenever a woman goes intolabour, a relative will go to the midwife’s house and ask her to supervise thebirth. Depending on the condition of mother and baby, others may be calledupon, often according to their age.
In the practical vision of these women, if a birth is to gosmoothly, what’s essential are the more human qualities, like attention andpatience. Perhaps that’s why Dona Francisca Tomé, the community’s oldestmidwife, is calm – even when a death occurs.
“It just makes me sad, because I try to do everything I can.Sometimes you don’t know why it happens. But no-one knows what happens when wedie. It’s neither good nor bad,” she reflects, touching the wooden crucifix shewears around her neck.
Lourdes’ husband sometimes puts pressure on her to leave theprofession, arguing that it brings in no money. Her response is always that childbirthis a situation of extreme difficulty and that the women need someone to supportthem.
For Lourdes, it’s birth – not death – which is the proof ofthe pain inherent to this life. “Only those who’ve given birth can know what itis. Doctors don’t know, husbands don’t know. We’re born thanks to the strengthof our mothers.”
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