“Three of my children died here,” comments a taciturn Lourdes Araújo 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 of Amazonas in northern Brazil.
Lourdes’ first two children had been suffering from complications and died after birth. However, her third, Maria, was healthy at the end of gestation, despite the military doctors having warned her the pregnancy was risky, as the 36-year-old Lourdes suffered from obesity and diabetes. It was Maria’s death which has had the biggest impact on her life.
Lourdes, of the Ticuna people, is an indigenous midwife by profession. On the day her waters broke, she decided she wanted a natural birth. But the doctors wouldn’t listen to her. “It was too early to pull her out,” she says. “I told them that, but they ignored me.”
At the time, the early 2000s, it wasn’t possible for anyone to accompany women going into labour in public hospitals. Despite her husband’s protests, he was prevented from entering the operating theatre to be at his wife’s side. He was only allowed to see her once Maria’s death had been confirmed.
Lourdes, now 52, shows me the photos she took of Maria after birth. There are lacerations on her arms and neck. “Look at how badly hurt she was. They were impatient, they pulled her too hard,” she says.
A study by the Fundação Perseu Abramo, a Brazilian thinktank, has found that some form of abuse – whether physical or verbal – occurs in one out of every four births in Brazil.
Modern techniques have increased the ability of obstetricians to decide how and when birth will occur, including the use of oxytocin; 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 by which Lourdes practises her profession. “A good birth must be done by the woman herself, in her own time. She has to discover herself; you can’t force anything. 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 its Portuguese initialism), 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 the logic of the Brazilian healthcare system. Fifty-six per cent of all births in the country in 2017 (the last year for which data is available) were carried out via caesarean section. In the private hospitals of São Paulo, Brazil’s richest 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 forefront of a troubling global phenomenon.
Global use of caesarean has doubled in the 21st century, despite the World Health Organisation (WHO) urging countries to ensure that their healthcare systems increase rates of vaginal birth. According to the research, in no more than 15% of cases is there a genuine need for this surgical intervention.
Despite this, one in every three babies born worldwide is still delivered by a midwife, according to the United Nations Population Fund. And it’s the countries which have effectively managed to combine tradition and modernity 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 healthcare professionals, even when the system tries to accommodate them. In a master’s thesis at the Fundação Oswaldo Cruz (Fiocruz-AM) entitled “Care offered by traditional midwives”, Ticiane Melo de Souza looked into this relationship, finding that some professionals tend to discriminate against midwives due to a rejection of their worldview.
This means that midwives’ knowledge – not only of childbirth, but also of pre- and post-natal care – goes to waste.
FROM GENERATION TO GENERATION
In general, the Ticuna midwives speak little Portuguese, live in modest houses and spend their time caring for expectant mothers, who sometimes 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 in which – 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. They might become involved through their family, but their licence to practise is granted by the wider community, which will call for them if any problem arises. Some of them 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 for generations. While she started out assisting expectant mothers on the Peruvian side of the Amazon River, the first baby she delivered was her own. She was just 16 and she was alone.
“I was standing up and I held onto the hammock. I didn’t know what to do or how to do it. I felt really alone,” she says. “It’s a rite of 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 she received. She has had 11 children, all of whom were born at home. “Always with the 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 is ignored.”
Another Ticuna woman, Páscoa Farias, participated in her first birth at 13, which was overseen by her mother. “It takes a bit of getting used to. There’s a lot of blood, crying. Men generally can’t handle it. You’ve got to be patient and kind. A birth can last seven, nine, eleven hours,” she says.
Lourdes, who is the leader of the Umariacu midwives, was introduced to the trade by her great-aunt. At first her role was just to watch and learn, but when she was 19, her sister-in-law went into labour and with no more experienced midwife available, she was forced to act.
Although the older women in her life had given her some instruction, 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 me to get a hold on its shoulder. At the time I didn’t know this, but later I realised that you might be helping at a moment of life and death. Making sure the women aren’t alone is the reason I like this work,” she says.
For Lourdes, caesarean contradicts the notion that giving birth is about patience and contact with our animal nature, principles that she maintains in her work. “[In hospital] The woman is there on her back waiting for 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 to get it over with because he’s got other work to do.”
CHILDBIRTH AS COMMUNITY RITUAL
Even when they know a birth will be complicated, the Ticunas prefer to place their trust in the older women. Whenever a woman goes into labour, a relative will go to the midwife’s house and ask her to supervise the birth. Depending on the condition of mother and baby, others may be called upon, often according to their age.
In the practical vision of these women, if a birth is to go smoothly, what’s essential are the more human qualities, like attention and patience. Perhaps that’s why Dona Francisca Tomé, the community’s oldest midwife, 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 we die. It’s neither good nor bad,” she reflects, touching the wooden crucifix she wears around her neck.
Lourdes’ husband sometimes puts pressure on her to leave the profession, arguing that it brings in no money. Her response is always that childbirth is a situation of extreme difficulty and that the women need someone to support them.
For Lourdes, it’s birth – not death – which is the proof of the pain inherent to this life. “Only those who’ve given birth can know what it is. Doctors don’t know, husbands don’t know. We’re born thanks to the strength of our mothers.”