The lineage of being midwives to save the lives of indigenous and rural women

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Martha Arotingo takes one end of the blanket and Luzmila Bonilla the other.

Jenny Morales is lying on a purple cloth, which both midwives hold firmly, but carefully.

Little by little, they move Jenny and her seven-month-old belly from side to side.

In silence, Bonilla continues rubbing his belly and says: “I feel like it's a little crossed.”

She refers to the fact that it is in a transverse position, that is, the fetus is in a horizontal position, instead of vertical.

Arotingo and Bonilla, Kichwa Kotakachi women, are two of the 1,913 ancestral midwives in Ecuador, according to data from the Ministry of Health (MSP).

Both women, in dark blue coats, white blouses and long braids, have dedicated their lives to accompanying, caring for and saving the lives of other indigenous and rural women.

Caring for women in labor is a ritual.

Before checking on Jenny and her baby, Bonilla asks permission.

She always does it.

“I'm going to touch my tummy, allow me, baby,” she says in a sweet voice.

In one hand, she holds a bottle of oil with chamomile leaves.

The midwife begins massaging Jenny's belly.

“This little belly is cold, it's empty, it's just swollen.

The baby is skinny,” Bonilla, 40, tells him.

While she continues rubbing his belly, the sound of the wind hits the white jute bags, which serve as windows of the plastered house, surrounded by towering corn plants.

Jenny always has a blanket tied to her belly, under her clothes.

“I feel like my belly is exposed and that's why I put on this blanket.

I may be sweating, but my tummy is cold.

I don't know why,” asks the 24-year-old woman, who is having her second child.

The first, three years old, is playing next to her while her midwife cares for her.

Bonilla tries to alleviate Jenny's discomfort with medicinal plants: she places custard apple leaves on her belly to “take away the cold” and she covers her again with the blanket.

Luzmila Bonilla shelters Jenny's belly, placing a hot frying pan on towels and blankets.KAREN TORO

Bonilla also uses cherimoya leaves to relieve Jenny from the cold in her belly.KAREN TORO

Martha Arotingo touches Jenny to recognize the position of her baby.KAREN TORO

“Before I knew I was pregnant, I was straining and carrying the bags of corn back and forth for the chicks.

She loaded cement, gravel and sand in the wheelbarrow for the construction of my house.

“She was pushing past, but I didn't know she was pregnant,” she says.

Jenny found out after almost four months.

“I was planning to have a month and a half, but it turned out I had three and a half months,” she says.

That day was her first prenatal checkup.

For women like Jenny, going to the medical clinic means dropping off her child, waiting for a bus for more than 30 minutes, or walking down a cobblestone slope into the city.

He lives in the commune of San Pedro, on the slopes of the extinct Cotacachi volcano, in the Andean province of Imbabura.

In these areas, where there is limited access to health services, the profession of midwives is vital, explains the family and community health advisor of the Pan American Health Organization (PAHO) Adrián Díaz.

“A woman who has to leave her animals, her son, and her family to travel an hour on an almost impassable road to go to a health center alone,” he says.

“That's not very seductive.”

Articulation between ancestral and Western medicine: a path to follow

Martha Arotingo, 39 years old, is clear.

She recognizes that, as ancestral midwives, she needs to integrate various knowledges of ancestral and Western medicine.

“We are responsible for the emotional work, accompanying the pregnancy and referring to a health center if we see that there is a complication,” she says.

For Arotingo, Jenny's case is important and reflects a problem: the Ministry of Health had to refer her to a midwife to visit her, accompany her and advise on nutrition with products that she has in the garden.

But that hasn't happened.

According to information from the ministry, the coordination between the public health service and ancestral midwifery consists of midwives referring pregnant women to the health facility for check-ups and, in turn, the health center referring cases to them.

But in practice it doesn't happen.

Martha Arotingo in the Partera di Anaku garden, which has plants used for pregnancy, childbirth and postpartum.KAREN TORO

“What the midwives have done is solve the problems within the communities with ancestral health,” says Arotingo, who leads the Partera di Anaku project, which seeks to create ties between other midwives, who are in different communities.

“We want to inspire, we want this profession to be seen as a health service, ancestral health,” says Arotingo proudly.

But, in addition, she emphasizes that her goal is to help young women like Jenny, with complicated pregnancies, malnutrition, precarious situations and contexts of violence.

The main executive of Health and Nutrition of the CAF-development bank of Latin America and the Caribbean, Luciana Armijos, points out that, in addition to geographical and economic gaps, indigenous and rural women face gender inequality.

“Violence and lack of education about their sexual and reproductive health rights are still a serious problem,” she points out.

This is in addition to the fact that gender violence in many indigenous communities is normalized and, in a certain way, accepted.

The following months after receiving the news of her pregnancy, Jenny has suffered from a weight deficit, she admits while lying in bed resting after being attended to by the midwives.

“From the beginning, I have been on a low line.

So far it doesn't fit the green line, I'm missing a kilo,” she says sadly.

She barely has enough money to eat every day, she says, and her house does not have basic services as essential as a bathroom.

Malnutrition is a problem that begins during pregnancy and, in many cases, continues throughout children's lives.

It translates into growing up with a disadvantage, in inequality.

In indigenous populations, malnutrition is alarming.

Three out of every 10 indigenous boys and girls under 2 years of age suffer from chronic malnutrition.

This is reflected in the latest National Survey on Child Malnutrition.

Armijos insists that the main difficulty is the care gap: “There are almost twice as many children with malnutrition in indigenous populations.

It is better than a couple of years ago and has integrated its cultural practices.

But many times they cannot get to the health facility no matter how free it is,” says the expert.

A mural on the wall of the Partera di Anaku facilities, in the Santa Bárbara commune, in Cotacachi.KAREN TORO

Giving birth in inequality

Access to health services is the most visible obstacle for indigenous women and women who live in the countryside.

In rural areas, five out of 10 (54.8%) have suffered obstetric-gynecological violence, according to the 2019 Violence Against Women Survey of the National Institute of Statistics and Censuses (INEC).

When it comes to indigenous women, the situation worsens: seven out of 10 have experienced this type of gender violence, which happens during pregnancy, childbirth and postpartum.

But there are other more structural ones, such as discrimination.

Martha Arotingo knows obstetric-gynecological violence.

She experienced it when she gave birth to her first child in a health center.

“They insulted me, yelled and said very ugly things.

I felt a lot of helplessness, anger and rage.

It was not a happy moment when you receive your baby,” she continues.

“I thought she was going to be like my mother cared for women in labor, with love and respect, like you, the most important.

But no,” she recalls.

Arotingo believes that this is one of the reasons why there is distrust within health services: there is no quality or warmth.

Luzmila Bonilla walks to a pregnant woman's house to attend to her.KAREN TORO

Ofelia Salazar Shiguano, leader of Amupakin—an association of Kichwa women midwives from Alto Napo, in the Ecuadorian Amazon—adds that, many times, when parturients go to health centers for pain, the doctors do not treat them.

“They tell them to come back when they have more intense pain, that there is still a long way to go or that's why you have a bus, hold on,” lists the 52-year-old woman.

“Those are not words for women in labor, much less just because we are indigenous.

In the queue for the turn to be served, the mestizo, first and the indigenous women behind.

That is another form of violence: because we are an indigenous woman, we receive worse treatment,” Salazar questions.

The lineage of midwifery

The legacy of midwives is almost generational.

It is transmitted from mothers to daughters.

It is a job that has come into their lives since they were children.

Salazar Shiguano is a woman who has known midwifery all her life.

Since she was a child, her mother would ask her for help when she went to care for a pregnant woman.

“When my

mom

attended a birth, she always said come, come, in Kichwa.

She takes this, passes this.

“It's like a game that we are taught since we were little,” she says.

When Arotingo thinks about midwifery, memories of her mother attending births and harvesting the land come to mind.

“My mother worked, she took care of the house, her children, she was a farmer and, at night, she went out and attended births,” he says.

Neither Marta Arotingo nor Ofelia Salazar had any plans to dedicate themselves to midwifery.

Both women decided it as adults.

After 15 years practicing the trade, Salazar feels happy to continue the legacy.

But at the same time she is worried about the future: “Moms are getting older and leaving us without their knowledge.”

Generational change is one of the survival risks of midwifery over time.

There are no young people who want to be midwives: the lack of recognition and financial remuneration is one of the causes.

The midwives Martha Arotingo, Luzmila Bonilla and Carmen Morán in front of the volcano known as Taita Imbabura.KAREN TORO

To change this reality, Martha Arotingo founded an ancestral midwifery school three years ago.

With the project, she wants women in the communities to come together and learn about midwifery.

For this, she put together a curriculum with all the knowledge that a midwife should know, ranging from gestational control, childbirth, postpartum and nutrition.

In addition to the professionalization of this ancient profession, Arotingo wants midwifery to be conceived as a health service, which has both monetary and professional validity.

“We want all women to have this strength to say yes, I am a midwife and that is my job, my profession,” she says enthusiastically.