AMA Journal of Ethics^®

Abstract

ESP

Until the mid-20th century, birth in the United States for Latinx Indigenous peoples was an ancestral ceremony guided by midwives and traditional healers (parteras curanderas). As American physicians and nurses increasingly differentiated themselves from traditional midwives, midwives of color in particular were disparaged and excluded from helping women give birth and thus from making birth a cultural foothold in their lives. As a result, communities of Latinx Indigenous peoples were culturally and spiritually separated—via the marginalization of parteras—from important health traditions, which caused suffering and illness. Reimplementation of birth as ceremony means babies can be born (and communities reborn) into an ancestral cultural ecology characterized by safety and cultural reclamation of healing.

 

Birth informs much of what scholars refer to as Mexican traditional medicine. It is a foundational paradigm of regeneration.... One way to understand birth as ceremony is to view the body as a container not only for the spirit, but also for principles of nature and life. Native people call these guiding principles “natural laws.”
Patrisia Gonzales¹

Marginalization of Community Midwifery

Until the mid-20th century, birth in the United States for Latinx and Indigenous peoples was an ancestral ceremony in which midwives and traditional healers (parteras curanderas) provided physical and spiritual care. Despite the immense challenges of working as a midwife in rural or poor communities, midwives saved lives and were beloved primary caregivers in traditional communities. Midwives not only attended births and provided prenatal and postpartum care, but also gave guidance on breastfeeding and on healing remedies for most reproductive ailments, worked with family physicians or obstetricians on serious cases, provided abortion care, and were even consulted for ordinary colds and injuries. Additionally, in many Indigenous communities, midwives were also seen as being able to cure spiritual illnesses (and consequently persecuted by religious inquisitors in the Americas), which contributed to community rituals honoring life passages, such as births, deaths, puberty, menstruation, and menopause. In Mexico, midwives are still considered “the inheritors of the prehispanic female doctor, the speakers for the goddess, the priestesses of life, [and] the protectors of health.”¹ At one time, within certain established systems of health care in the Americas (although not in the United States), midwives were even considered on par professionally with physicians.²

In the 1930s and 1940s, US obstetricians increasingly differentiated themselves from traditional midwives by enacting standardized medical school curricula, formal credentials for practice, and professional societies with the authority for self-regulation, all with a focus on the pathology of “dangerous” childbirth.³ This marginalization of traditional and fundamental healers (such as parteras) has separated Latinx Indigenous communities from their cultural and spiritual health. Indigenous midwifery is based on communal, spiritual, and bodily knowledge, and birth is viewed as a natural part of the life cycle as opposed to the scientifically or medically sanctioned model of birth that generations of Indigenous communities had forced upon them.¹

La Partera Curandera

In the 1930s, although not legally recognized with licensure in North America, traditional parteras were actively working in underserved communities in the United States. In New Mexico’s San Miguel County, parteras attended 72% of all births in 1936.⁴ One midwife in the region, Jesusita Aragon, attended 12 000 births in her lifetime in the region of Las Vegas, New Mexico, as one of the last remaining traditional midwives in New Mexico.⁵ Yet, at the turn of the 20th century, midwives had begun to be marginalized as newly professionalized doctors, with the support of their middle- and upper-class patients, encouraged hospital delivery to ensure the safety of mother and child.⁶ Slowly, the communal and intimate nature of midwife-attended births, wherein only the most difficult deliveries were attended by physicians, became medicalized, thereby merging “ordinary” and “emergency” practices.⁷ As Laurel Ullrich notes, this trend “demanded the elimination or further subordination of social healers. To allow a woman to continue to practice midwifery, or, by extension, any other form of independent healing, deprived male doctors of the experience they needed and at the same time perpetuated the notion that un-educated people could safely care for the sick.”⁷

This narrative of Indigenous-based medicine as unsafe, unscientific, and unhygienic meant that midwives would continue to care for families in communities that were not being served due to rural geography, racism, or poverty. Traditional midwives were blamed for poor outcomes and no longer seen as healers but instead as old, illiterate midwives of color with suspicious cultural practices.⁸ Traditional White midwives serving poor communities (such as Appalachian midwives) were considered similarly bereft of education but cast as heroes worthy of support or (if economically resourced) trained as obstetric nurses under the watchful eye of the medical system.⁹ Physicians of the time referred to the “midwife problem” of poor midwives of color who needed to be eliminated or reformed via supervised nursing.¹⁰

Elimination of US Midwifery

Between 1945 and 1965, the number of parteras in New Mexico fell from 800 to under 100, a decline that was accelerated by New Mexico’s implementing regulations in 1979 that required midwives to have formal education and pass a written licensing exam.⁴ In the United States, more and more states began to convict midwives or demand that they be licensed regardless of experience or years as a birth attendant, and, for many parteras, licensing was not accessible due to financial, geographic, literacy, or educational barriers.¹¹ Even in areas such as Puerto Rico, where Latinx midwives were registered, midwives disappeared entirely by 1970.¹²

By the mid-20th century, the diverse ways in which Latinx and Indigenous communities honored birth and death in the hands of traditional healers—with traditional medicines and ceremony and forgoing interventions in a hospital setting—were deemed dangerous and irresponsible by policymakers favoring medicalized, profit-making health systems.⁸ Communities of color were assimilated into the health care system, but their parteras were replaced with obstetrical nurses. Women were birthing in hospitals that reflected neither their cultural customs nor community members and were often far from home. As a result, people of color and the poor were denied their culture of health shared with parteras and for decades faced mistreatment in the hospital, separation from community, and medical interventions, such as sterilization, done without consent.^13,14

This cultural and social elimination of midwifery was accompanied by the medicalization of childbirth by White men who viewed the bodies of pregnant women of color as “things in need of regulation … because it subconsciously allows for the perpetuation of race, gender, and class hierarchies and structures.”⁸ Moreover, as Danielle Thompson notes:

[T]he scholarship and data … show us that these stereotypes have had startling, statistically significant, and systematic effects on pregnant women and mothers of color…. Increased control of pregnant and reproductive-age women of color paralleled and directly intersected with midwifery regulation by using seemingly scientifically and socially necessary measures such as eugenics-based anti-miscegenation laws as well as birth reporting laws.⁸

Viewed as uneducated, inferior practitioners, parteras that did continue to practice lacked support from local health care systems. Legal recognition could have helped midwives and their patients by generating formal education opportunities and financial resources to counter maternal and newborn mortality, particularly in Indigenous and Black communities, and especially in communities with neither physicians nor health centers.¹¹ In Mexico, midwives were used as scapegoats for poor outcomes by physicians or local officials.¹⁵

Some of the most significant negative influences of US acculturation can be seen in reproductive and newborn health.

Much was and is broken in how the Latinx community attends to birth and the postpartum period. Ironically, as the Latinx community acculturates, its propensity for good health declines despite greater health care use in a process known as the Hispanic paradox.¹⁶ Some of the most significant negative impacts of US acculturation can be seen in reproductive and newborn health. Studies have found that as Latinx peoples become more acculturated, their rates of infant mortality, low birthweight, and prematurity increase significantly, and they are more likely to have unhealthy behaviors before birth and after birth, including decreased breast feeding.¹⁶

Restoring Cultural Healing Practices

There has been little success in honoring the traditional roots of Latinx healing at a systemic level since the Americas established male-centric European models of institutionalized health care. According to Mitchell Kaplan and Antonio Zavaleta: “The importance of Latino cultural beliefs in health care and our failure to fully understand or incorporate them into the clinic setting, and our general lack of attention to culture, has greatly impaired our ability to deliver appropriate health care to the Latino population in America.”¹⁷ Within the current US hospital system, the most sacred Latinx traditions concerning reproduction, birth, and the critical nurturing care of parent and newborn are generally absent, particularly for immigrant families separated from one another and their supportive cultural and ceremonial traditions by border politics and economic realities.

Although colonizers and institutions eliminated the tradition of community birth, which is absent in the recent memories of our elders, ceremonial ways of birthing can be rewoven. Patrisia Gonzales describes the promotora-investigadora, wherein the validation of healing knowledge is integral or “cellular” to Mixteco and Indigenous peoples even with this enforced disconnection from birthing ceremonies.¹ A culture of healing can be found instinctually regardless of the geography of the Latinx diaspora and regardless of whether one is displaced as an immigrant in another country or is rooted in one’s ancestral village: “through stories, symbols, acts, and events, people create ways to frame their knowledge and assert their self-authored ways of being and knowing. They help to create the ‘therapeutic landscape’ and the evocative power of place on health.”¹ Cellular healing is there when we recall our abuelita’s medicinas or when we sit by a gobernadora bush after a desert rain. Ceremony is in taking manzanilla tea for comfort or a bath wherein a matriarch washes spiritual illnesses down the drain and a midwife buries the placenta deep in the sacred earth for the baby’s lifelong protection and connection to the land.

Another way of recreating ceremonial birthing is through encoded knowledge, which encompasses the quiet healing ceremonies of communities as part of survival and is embedded in symbols and codes. This encoded knowledge has survived largely because women healers and ancestors have guarded the knowledge for future generations.¹⁸ We carry the sacred healing within as borders are crossed, poverty and discrimination are endured, and machismo and inaccessible health care endanger the lives of our mothers and newborns. Perhaps this ancestral endurance contributes to another Hispanic paradox, whereby US Latinx peoples have a longer average life expectancy than non-Hispanic White people.¹⁸

Encoded knowledge of Latinx and Indigenous communities is genetically inaccessible to outside researchers and data miners whose research often yields mythical farce, incomplete data, or the academic narrative of an outsider unable to center Latinx epistemologies. There is a true need to decolonize research, such that the underlying assumption that mainstream medical methods are objective would be seriously challenged.¹⁹

A community, all its relationships and lifeways, can splinter when foundational healers are deemed irrelevant. It was not so long ago that the parteras and other medicine peoples were considered gifted by the Creator, connecting those in the community to the healing of their ancestors, to their ecosystem, to their traditional foods, and to themselves. If we imagine the return of birth as ceremony, as the basis of our ancestral healing ways, babies would be born into an ecosystem of cultural safety. Although so much precolonial history of birth has been erased, forgotten, and destroyed by the colonizers, I believe the ancestors whisper: “Our culture heals us.”

Re-Indigenous Birth in the Americas

Grassroots revival of traditional birth work is taking place all throughout the Americas, with many traditional birth workers wanting the integration of ancestral medicine to be respected within their professional licensure. In Canada, midwifery laws have started to include an expanded scope of practice for First Nations midwives in that country,²⁰ inspiring those of us in the United States to consider what innovative regulations can be worked on for midwives serving Indigenous communities. The root causes of maternal mortality are often a lack of access to care and to caregivers grounded in cultural understanding, as well as a lack of reproductive health care practitioners overall in the United States. The United Nations Population Fund report, “The State of the World’s Midwifery 2021,” makes it clear that, if given the supportive infrastructure, midwives are the solution to counter the high rates of maternal mortality and morbidity in communities of Black, Indigenous and people of color (BIPOC).²¹

The revitalization of birth as ceremony is a way to recover the humanity of one’s indigeneity, the connection we as Latinx peoples have to the natural world and to community health. As Latinx communities became “deceremonialized,” they became separated from culture, kinship, ceremony, story, narrative, art, music, and means of education.²² In the last 2 decades, BIPOC-led organizations with a focus on reproductive justice, data sovereignty, and reclaiming health as a human right have been growing in number. Many are working exclusively on policy to provide access to midwives for Indigenous communities by opening Indigenous-led birth centers and midwifery practices, creating community-based certification programs and educational opportunities for Indigenous students, and supporting medical practitioners who wish to use traditional medicine and ceremony in hospitals or health care settings.^{23,24,25,26,27,28,28,30,31} As the only Indigenous midwife in my state when I was licensed in 2003 (indeed, the only midwife of color), I am now part of many well-funded coalitions and groups dedicated to Indigenous healing in reproductive health across the United States. To bring ceremony back to birth is the radical process of rehumanization and connection to the divine. It is also a radical reimagining of what culturally based and sovereign systems of reproductive health care and data collection would look like when created by and for Indigenous communities. L. T. Smith writes:

[T]here is a point in the politics of decolonization where leaps of imagination are able to connect the disparate, fragmented pieces of a puzzle, ones that have different shadings, different shapes, and different images within them, and say that ‘these pieces belong together.’ The imagination allows us to strive for goals that transcend material, empirical realities. For colonized peoples this is important because the cycle of colonialism is just that, a cycle with no end point, no emancipation. The material locates us within a world of dehumanizing tendencies, one that is constantly reflected back on us. To imagine a different world is to imagine us as a different people in the world. To imagine is to believe in different possibilities, ones that we can create…. Decolonization must offer a language of possibility, a way out of colonialism.¹⁹