Margarita Morales, a 55-year-old indigenous midwife in Ecuador, pressed her fingers against the belly of a young pregnant woman at a clinic in Otavalo, a mainly indigenous community about two hours from the capital city of Quito. This is how Morales determines the intensity of contractions and predicts how much longer it will take to give birth. She doesn’t use a speculum, ultrasound machine, or blood tests; rather, this midwife relies on years of knowledge passed on by her grandfather, who began teaching her how to care for pregnant women and new mothers when she was 11 years old.
Morales’ most important skill involves a form of childbirth preferred by indigenous mothers in Ecuador: vertical birthing. This method allows women to remain upright during childbirth so that the baby’s head passes more easily than if lying down with feet in stirrups. Vertical birthing is also often healthier for the mother and child — it’s associated with fewer episiotomies, Caesarean sections, and fetal heart rate abnormalities, as well as less pain. It’s also culturally preferred in many indigenous communities in Latin America.
Until recently in Ecuador, vertical childbirth was rarely accepted as a legitimate form of healthcare. And indigenous midwives — also known as parteras — like Morales weren’t allowed in operating rooms with their patients.
But a recent program to improve maternal health in Ecuador means that doctors are seeking their expertise to integrate vertical birth into the state healthcare system. And it’s working.
IIn the past decade, Ecuador’s poorest citizens have seen dramatic improvements in their quality of life. Former president Rafael Correa, Ecuador’s controversial leftist leader whose term ended in May 2017, brought continuity to the Andean nation that saw nine presidents in the 10 years before him.
This allowed his government to prioritize social programs in what has been called the Citizens’ Revolution. Since 2007, Ecuador has lifted 1.5 million people out of poverty, pushing them over the monthly salary threshold of $80 USD per person. School enrollment saw a 15 percent increase for students ages 12 to 17, now at about 81 percent. Ecuador built more than a dozen new public hospitals under Correa and increased the number of public hospital beds by more than 20 percent.
Ecuador also had the most progress of any country worldwide in reaching the Millennium Development Goals — though it fell short of the target of reducing maternal mortality by three-quarters. This is in part because many women, particularly from indigenous communities, choose not to go to a hospital to seek care, a tendency that is slowing changing as the country implements more culturally sensitive health programs. This too is changing: according to UNICEF stats, 81 percent of women in rural Ecuador (where the indigenous population is concentrated) gave birth in an institution in 2012, up from 66 percent in 2006.
“I once had a bad experience at a hospital and that’s why I prefer to go to Margarita’s house,” said Marisol Pilca, a 23-year-old indigenous mother with a four-month-old baby. “Doctors sometimes treat women poorly, so I prefer to go to a partera.”
Attitudes like Pilca’s are prevalent in Ecuador. “Indigenous women often feel the services provided are not culturally appropriate,” said Ana Lamas, a researcher at the London School of Hygiene and Tropical Medicine who has studied the vertical birthing method in Ecuador. “They want quality services and they want to feel that their practices are respected.” Overall, she said, the healthcare system has historically failed the country’s indigenous women, who often prefer non-invasive medical care, live in isolated areas, and speak Spanish as a second language.
EEcuador introduced the vertical birthing program in Otavalo in 2007 as a result of lobbying by indigenous groups who were fed up with being left out of the healthcare system. Ecuador’s Health Ministry implemented a program called “Attention for Culturally Appropriate Birth” that included remodeling hospital rooms to include ropes and bars to aid women in vertical birth, offering indigenous women special garments to fit standards of modesty and allowing parteras to accompany women in the delivery room.
Doctors were given training sessions to learn the parteras’ methods and the importance of intercultural health.
The most important thing these midwives taught doctors was something they weren’t able to learn through a textbook: how to interact better with their indigenous patients.
“The most important thing I learned [from the parteras] was that we have to treat human beings as they deserve, with respect and care,” said Patricio Inlago, a 39-year-old doctor who participated in the program. “In medical school, they don’t teach you about how to merge the physical, emotional and spiritual.”
In turn, parteras were taught to recognize signs of serious complications that would require transporting a woman to the hospital.
“For some, parteras will always be uneducated people who don’t know anything about healthcare and aren’t qualified,” said Darwin Tamba, director of the Jambi Huasi, a health clinic in Otavalo that focuses on providing intercultural healthcare to the indigenous community there. “But in reality they have a lot of knowledge about healthcare. Here at our clinic, we give them 100 percent confidence to carry out their work, but that has not always been the case in the public sector.”
After the program was introduced in Otavalo, which has a 110,000 population, there was a notable decrease in maternal mortality cases. In the first three years the program was implemented, there were zero deaths during childbirth, compared to 10 deaths over the previous four years.
The program in Otavalo was recognized internationally with an award from the Pan American Health Organization in 2012, celebrating its success in reducing maternal mortality by implementing culturally sensitive care. The program has since spread to other parts of the country with large indigenous populations from the Amazon to the western coast. From 2005 to 2015, maternal mortality in Ecuador decreased from 74 to 64 deaths per 100,000 live births (by comparison, the United States has a maternal mortality rate of 28 per 100,000 live births).
Getting indigenous midwives inside hospitals has other benefits; specifically, it encourages their patients to give birth in health facilities instead of at home. This is particularly important in cases when women experience serious complications during childbirth and need a larger medical team and resources.
Once the parteras were allowed in the hospital, more indigenous women started to come,” Tamba told me. “One of the reasons that women historically haven’t gone to the government health centers is because they don’t find their traditional medical practices there. There’s a lot more trust within these communities, because of the language and customs.”
Despite the successes of the program, Tamba believes there is still work to be done. The maternal mortality rate has been greatly reduced in Otavalo, but many indigenous women still struggle to get appropriate care in other parts of the country. In cities, he said, this type of culturally sensitive healthcare is nearly nonexistent.
“This program was at least an opening to start talking about policies in this way, to create norms and laws for maternal healthcare that is culturally appropriate,” Tamba said. “My dream is that the government has culturally adequate healthcare policies throughout the country. It’s their obligation.”
Last week, on May 24, Ecuador experienced its first major political change in a decade, when President-elect Lenin Moreno took office. Moreno — former vice president to Correa and a candidate from the same party — will likely continue to prioritize social programs targeted at increasing the quality of education, healthcare, and living standards for the country’s most marginalized populations.
This includes the indigenous community in Otavalo, where midwives like Morales have provided healthcare for centuries. Parteras don’t plan on fading away any time soon. Morales will continue to help women give birth at home or in the hospital, offering them soothing words in their native language and practicing the non-invasive methods taught to her by her grandfather.
“We indigenous midwives are part of the traditional customs,” Morales told me. “We are necessary to save lives.”
