In Mexico, as elsewhere in Latin America, newborn mortality among indigenous peoples is higher than in the overall population.

Experts think this situation would improve if pregnant women and their newborns could be referred with sufficient time to government or private health services in case of complications during delivery or shortly after childbirth. Over the years, national and international health agencies have gone even further to advocate that all pregnancies should be closely monitored by medical personnel and all births supervised by skilled professionals with at least 10 years of general education and several years of specialized training.

As a result, many safe motherhood and child survival programmes have tried to persuade indigenous peoples to give up long-held practices, like giving birth at home, with little regard for their views and cultural values. Indigenous women, particularly in remote areas, have shied away from government health facilities for a number of reasons –ill treatment, poor and irregular services, disregard for their traditions, fear of unnecessary episiotomies and c-sections. In other communities, where indigenous people have lost their mother tongue or where they live closer to hospitals, birth traditions seem to be receding. From a biomedical standpoint, this could be hailed as a success, but it certainly comes at a high cost for many cultures.

We are set on a different course. CIET is attempting to draw on both indigenous and biomedical knowledge and practices to improve maternal and perinatal outcomes in Xochistlahuaca a remote rural municipalitiey with majority indigenous populations (Nancue ñomndaa or Amuzgo) in Guerrero, one of Mexico’s poorest states. We hope to demonstrate that this culturally respectful way of doing things can be of use in indigenous settings across Latin America.

We have partnered with the Association of Indigenous Amuzgo Health Promoters of Xochistlahuaca and the State health authorities to carry out a cluster-randomised controlled trial with active participation from local indigenous people. Our hypothesis is that supporting traditional midwives is no less effective in reducing maternal mortality than current health services and that it adds value through other health-related advantages including reduced surgical interventions, reduced infections, increased choices, and increased social capital.

From the baseline survey we were able to identify those women who were known as traditional midwives by their communities. Stratifying by number of deliveries attended, we randomiese these midwives to intervention and control groups. Four authentic traditional midwives who together had attended 88 deliveries over the previous two years constituted the intervention group.

The intervention included:

1. Stipends for traditional midwife and trainee midwives;

2. Support for health brokers (técnicos interculturales) to arrange transport for referral of complicated cases, negotiating birth certificates for non-complicated cases delivered by traditional midwives, and providing interface with the health services;

3. We asked the midwives what assistance they needed to carry out their role. Three of the four, who were elderly and had difficulty travelling long distances over difficult terrain asked to have simple community birthing centres constructed near to their own homes, These were single-room premises with water supply. They provided clean birthing conditions and facilitated participation of apprentice midwives in the birth process. The fourth midwife who was younger, whose clients lived mostly within easy access and whose own daughter was her apprentice did not request a birthing centre.

Limitations of time and money precluded our obtaining statistically significant data on maternal or neonatal mortality. Nevertheless, preliminary results from the follow-up survey show that the intervention group reported around one half the birth complications reported by the control group. Significantly fewer women in the intervention group delivered without any outside assistance, fewer had surgical interventions or post-delivery infections, and they paid less despite government obstetric services being supposedly free.

We do not deny that there are certain birth complications like obstructed labour that can be dealt with only by highly skilled professionals in hospitals or hospital-like conditions. But in many parts of the world these skills and the necessary equipment are in short supply and far removed from those who most need them. Supporting authentic traditional midwives can help to decongest secondary and tertiary obstetric services, allowing these resources to focus on cases where they are most needed.

The approach of this project is to foster an intercultural dialogue that supports both traditional midwife and Western obstetrician to do what each does best.

A short video in which Dr. Neil Andersson elaborates on the theme of safe birth in cultural safety is available at: http://www.youtube.com/watch?v=QHDiBawGVZ4