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Anthropological Perspectives on Global Issues in Midwifery
by Robbie Davis-Floyd, PhD
© 2000 Midwifery Today, Inc. All Rights Reserved.
[Editor's note: This article first appeared in
Midwifery Today Issue 53, Summer 2000.]
A distressing cross-cultural trend is showing up in the growing body
of anthropological literature about midwifery and birth in the developing
world. From Tanzania to Papua New Guinea, anthropologists who observe
professional midwives giving prenatal care and attending births increasingly
note that, far from the midwifery ideal, professional midwives often
treat women very badly during birth, ignoring their needs and requests,
talking to them disrespectfully, ordering them around, and sometimes
even yelling at them and slapping them. At the same time, and in direct
correlation, the professional midwives are themselves often treated
badly by the healthcare systems in which they work. They are almost
always underpaid, are frequently mistreated by physicians who rank above
them in the medical hierarchy, and generally work long hours under stressful
conditions that often include inadequate facilities and equipment and
too many women with too few midwives to care for them well. In short,
professional midwives are often trapped in the biomedical healthcare
system, a system that is failing to meet the needs of birthing women
in developing countries.
According to the international definition, a midwife is one who graduates
from a program duly recognized in its jurisdiction. In the developing
world, this generally means a two-year government training program.
The women who attend these programs are usually young, often fresh out
of high school, and have borne no children themselves. They are educated
in an urban environment, then sent out to serve in a rural village,
where they wear the white coat and expect respect from the townspeople
for their professional, educated status. They usually work in the government-built
clinic, but for an extra sum of money will sometimes attend a homebirth
if they are called. These government clinics are usually underfunded
and understaffed, and often the drugs with which they are supposed to
be stocked are sold out the back door by clinic staff to compensate
for the inadequate salaries they are paid. Recent anthropological ethnographies
describe indigenous women in India, Mexico, Tanzania, Papua New Guinea,
and elsewhere saying the same thing about the care they receive in these
clinics: "They expose you, they shave you, they cut you, they leave
you alone and don't come when you call, and they won't allow your relatives
to be with you." Here is a highly representative quote from an article
by anthropologist Pauline Kolenda describing birth in a hospital near
a small village in India:
Before entering the hospital we have first to decide how much money
we have to give. We are not admitted unless we first give them money. When the
woman enters into the hospital, the doctor behaves rudely with her. Sometimes
nurses beat her. They do not let close and affectionate relatives, who came from
home with us, stand at our side. They themselves either do not stay near us. We
wish that somebody hold us by the waist when pains come, but they do not do it.
We have not even to moan, lest they talk sarcastically, make fun of us, which
is very hurting, still we have to bear. If we moan too much, they may sometimes
slap us. If we happen to say something, they retort by asking us whether they
had invited us to come. "Why have you come then? You may go back home!" In hospital
we have to lie down on the bed to get delivered. In the hospital they excise the
vaginal wall with a blade for enlarging it. The body gets damaged unnecessarily.
After delivery we feel terribly hungry, but we consider ourselves lucky if we
get a cup of tea.
Not surprisingly, even though the governments of these countries have
embarked on massive programs to bring birth into the clinics and hospitals,
many rural women resist, choosing instead to birth at home with a community
midwife. Officially labeled "traditional birth attendants" (TBAs) by
WHO and UNICEF because they do not meet the international definition
of a midwife, these community midwives are usually older women who have
given birth several times and who have become midwives by being asked
to attend the births of friends and relatives, slowly gaining first-hand
experience of birth. Some of them undertake long apprenticeships with
experienced community midwives, while others learn simply by attending
births. From the point of view of villagers and townsfolk all over the
developing world, the biggest difference between community and professional
midwives is that community midwives are recognized by their community
as midwives, while the professionals are often seen as young and inexperienced
women who have to prove their worth to the villagers before they can
When the professional midwives make a sincere effort to learn about
and honor local customs and traditions, when they approach local people
with an attitude of respect and demonstrate willingness to work with
community midwives, honoring them as colleagues, this hierarchical system
can function efficiently. In such cases, community midwives are generally
very willing to advise women to go to the clinic or hospital in situations
of risk, and will often accompany them there if they are sure of being
well received and of getting adequate care for their clients. But when
doctors and professional midwives approach the community with an attitude
of arrogance, treat the "TBA" with disdain, and punish women who attempt
homebirth by treating them badly when they do transport—an all-too-typical
situation-a consensual agreement is made among mothers and their at-home
attendants to avoid the clinic or hospital at all costs. Such a situation
leaves the community midwife to cope with emergencies at home as best
she can, often until it is too late to seek help. If disaster befalls,
of course, it is she who takes the blame, when in fact the fault may
lie in the dysfunctionality of the system.
Debora Barnes-Josiah and her colleagues have shown that in Haiti,
as in other countries, a lack of confidence in available medical options
was a crucial factor in delayed or never made decisions to seek medical
care. They suggest that improving the quality and scope of care available
at existing medical facilities will prove crucial in reducing needless
maternal deaths. Likewise, Soheir Morsy has shown that in the rural
area of Egypt she studied, traditional midwives were getting blamed
for the high rates of maternal mortality, when in fact most of the deaths
occurred among women who had given birth in the hospital as a result
of complications from cesarean sections.
UNICEF, WHO and those engaged in implementing the Safe Motherhood Initiative
have for two decades centered their efforts to reduce maternal and perinatal
mortality in the Third World around "TBA training'—short, usually
two-week-long courses taught by medical personnel, usually doctors,
nurses, or professional midwives to community midwives. The purpose
of these courses has generally been to educate TBAs about the risks
that require transport and to improve their prenatal and maternity care.
Of course, these courses too have been plagued by the same systems failures
as the situations I describe above. Almost always, these courses are
designed by biomedical personnel trained in biomedical institutions
to think about and manage birth in biomedical ways. Very seldom do the
"trainers" enter a community and spend time there learning about the
indigenous birthways before they try to intervene. Rather, they attempt
to educate traditional midwives in biomedical ways of thinking that
are often totally inappropriate to local circumstances and realities.
For example, perhaps the local custom is to cauterize the cord with
a candle flame after cutting it. Trying to replace that sustainable
custom with Merthiolate in a place where supplies are scarce and Merthiolate
unavailable or expensive is an unsustainable and inappropriate intervention,
but one nevertheless that typifies this training approach. Far more
seriously, TBA trainers often think their job is done if they succeed
in educating midwives about the multiple conditions that are biomedically
deemed to require transport to a clinic or hospital. The training complete,
they leave, and the midwives get blamed if they do not transport for
the risks they have just been educated about.
In Mexico and other countries, UNICEF has just discontinued funding
for TBA training courses; since maternal mortality rates have not dropped
after twenty years of TBA training, the conclusion is that they do not
work. This conclusion is based on the assumption that mothers die because
midwives give them inadequate care or fail to transport them in cases
of need. But as we have just seen, sometimes it is the hospital that
gives inadequate care. And often women in need are simply unable to
reach the hospital. I remember well when Dona Nieves, a very short and
very experienced traditional midwife from rural Oaxaca, Mexico, bravely
stood up in the big auditorium in Mexico City in the middle of the Safe
Motherhood Conference and said to all assembled:
Do not blame us for failing to transport women. We know when we
should transport. But none of us own cars, nor do our clients, the buses run very
irregularly, there is no ambulance service and if there were our clients couldn't
pay for it, and the only taxi driver in our town charges far more than our women
can pay. How then do you expect us to get our clients to the hospital in the city
an hour away? No, we can't, we just have to do the best we can with no help from
anyone. If you want me to transport women who need to go to the hospital, give
me a car!
Another traditional midwife from Oaxaca, Dona Queta, described to me
how a woman arrived to her tiny village high in the Oaxacan mountains
many years ago. The woman, nine months pregnant, had tripped over a
piece of wood and fallen hard. As she got up, she felt the baby move
once, and then no more. Afraid that the baby had died, the mother walked
for two days over the mountains to get to Dona Queta's home. By the
time she arrived, said Queta, the odor around her was foul and it was
obvious that the baby was dead. What to do? The woman had arrived alone
and penniless. Dona Queta went to fetch the one doctor within 100 miles,
but he was away on a trip. So she spent the next three days pouring
liters of antibiotic herbs into the woman and praying for her life.
Finally the woman went into labor and gave birth to the dead fetus,
and then almost died herself from massive infection. But Queta persevered
with the antibiotic herbs and other nutrients, the rituals, and the
prayers, and two weeks later the woman walked home alive and well. When
the doctor arrived back from his trip and found out what had happened,
he scolded Queta for taking on the care of this woman, but had to back
off when he realized that he had left her with no other choice besides
leaving the woman to die on the road.
In an ideal world, the community midwife is the first line of care
and is backed up by professional midwives, doctors, and the biomedical
system. In the real world, often there is no backup or no way to get
to it, and she must handle whatever comes as best she can. Clearly,
the solution does not lie in giving her superficial training in biomedicine
and expecting her to get women to the hospital when they need to go;
rather, the solution must be found in a system-wide approach that requires
as much flexibility of biomedicine as it does of the community midwife.
Consider for example the case of the Karimoja, a rural tribe of cattle
herders in a remote comer of Uganda. British midwife Sally Graham went
to Uganda some years ago to work in a public health clinic serving the
Karimoja. Matemal mortality rates were high among this group, and Graham
wanted to improve maternity care. She had been trained to think that
the Western system was the best; nevertheless, it occurred to her that
it might be a good idea to learn about the indigenous system before
trying to change it. Slowly getting to know the local midwives, she
eventually developed good enough rapport with them to suggest weekly
meetings during which they could engage in mutual discussion of their
different techniques. Graham discovered over time that these midwives
had many skills; she came to realize just how many one day when a wizened
older midwife came running out to stop Graham's Land Rover, waving her
hands excitedly. She told Graham she was very sony that she would miss
the meeting that day; she had to stay home as both her daughter and
her daughter-in-law had given birth the night before to twins. One of
the twins (the second to emerge) had been transverse, and she had to
do an internal version to get it out. Both mothers, and all four babies,
were doing well!
It turned out that the indigenous system didn't really need changing;
the problem lay, as it so often does, in the interface between the biomedical
and the indigenous systems. Karimoja midwives who transported were often
rudely and dismissively treated, so they tended to hold on at home longer
than was wise in order to avoid subjecting themselves and their clients
to such disrespect. Graham's solution was to bring the clinic staff,
two at a time, to the weekly meetings she held with the midwives. As
the staff developed more respect for the community midwives, they invited
them to the clinic for tours and get-acquainted sessions. Then when
the midwives transported, their advice was respectfully solicited and
listened to, and they were invited to remain with their clients and
give labor support. This model of mutual accommodation, which Graham
called the "partnership paradigm" was implemented over live years ago
as a result of Graham's work and is still functioning well. (It reminds
me of the models American direct-entry midwives often develop with doctors
and hospitals in their communities. After years of mistreatment by hospital
personnel, over time they earn their respect and develop good working
relationships that exemplify Graham's partnership paradigm.)
All over the developing world, in spite of the massive dysfunctionality
of most obstettic systems, it is possible to find models that work.
The system that Dr. Galba Araujo developed in northeastern Brazil is
one prime example. Araujo was the head of OB-GYN at a tertiary care
center in Fortaleza, Ceara', Brazil. Concerned about high mortality
rates in the rural regions his hospital served, he went out to the rural
communities and asked the midwives what was needed. Their answer was
that women needed a clean and safe place to give birth; most of their
houses had dirt floors, and cleanliness was almost impossible to maintain.
So he created a system of maternity care clinics in numerous rural villages.
These centers were equipped with donations from local villagers: anything
was welcome, from a fork to a plate to a chair. Each center was equipped
with the hammocks in which local women preferred to give birth, and
with the drugs and equipment that Dr. Araujo felt the midwives should
have. He also created an efficient ambulance system, so that transport
was readily available should the midwives call for it. Outcomes in these
maternity centers were so good that Dr. Araujo began to study what the
traditional midwives did, and ended up incorporating hammocks, more
patience, and upright positions for birth into the hospital. This system
functioned efficiently until his death; it has since been dismantled
due to lack of support and interest on the part of the younger obstetricians
who replaced him. While it existed, this system was an excellent example
of Graham's "partnership paradigm" or what Brigitte Jordan
has called "mutual accommodation" between biomedical and indigenous
In 1978 with the publication of Birth in Four Cultures, Jordan issued
a call for the replacement of top-down, culturally inappropriate, biomedically
oriented systems with models of mutual accommodation like the ones Dr.
Galba and Sally Graham created. But the worldwide hegemony of Western
biomedicine has made this kind of mutual accommodation an elusive goal.
Why bother to accommodate to a system you regard as inferior? Why not,
as has so often been done, demand instead that the indigenous system
change to accommodate biomedical ways of knowing and managing birth?
The answer is quite clear of course: biomedicine is an inappropriate
model for birth in any culture. It is too costly, too interventive,
too drug- and technology-oriented, and does too much harm to mothers
and babies for it to be a viable model to which developing countries
should aspire. Nevertheless, because of the general global dominance
of the West, the legacy of colonialism, and the dramatic successes of
biomedicine, all developing countries do aspire to meet the standards
set by Western medicine, standards that are inappropriate for birth
and indeed for many of the world's health needs.
Consider the following description of a hospital birth in rural Papua
New Guinea from the doctoral dissertation of Julia Byford, an Australian
nurse-midwife who has become an anthropologist:
Mispa, a young woman of twenty, was admitted to the hospital this
morning. She is seen by the Health Examination Officer, who does a vaginal exam
and tells me that she is four to five centimetres dilated...and that she may commence
a Syntocinon infusion...The labor room is small and the air conditioning unit
mounted high on the wall belches cold air at us. When it is on the room gets very
cold: when it is off the room gets hot and stuffy. There is a sink but no plumbing
to allow it to be operational. There is no water at the hospital today anyway
.... Mispa asks to sit on the floor and is given permission to do this, but as
her labour progresses the nurse says she must stay on the bed so the staff can
do their observations. She acquiesces and does not ask for anything else. Most
of the time she is left alone. She has not eaten all day and only drunk a small
amount of water. Her lips are dry and swollen. The staff do numerous vaginal examinations
but none of them are recorded [so when a shift changes, another exam is performed]....
During the second stage of labour, every time Mispa has a contraction,
the Health Examination Officer inserts a few fingers into Mispa's vagina between
the perineum and the baby's head in order to stretch the perineum. Mispa finds
this excruciating and tightens her grip on my arm...[After the birth] I am dismayed
although not surprised to see that the baby is flat and pale and requires resuscitation.
The HEO delivers the placenta by placing one hand on Mispa's abdomen and pulling
on the umbilical cord with the other hand...As soon as the placenta is out, Mispa
has a large postpartum hemorrhage. The HEO asks me to increase the intravenous
infusion rate and then inserts her hand high up into Mispa's vagina and manually
removes some retained placental pieces. This is done without explanation or anesthetic....
Perhaps the hardest thing for me to come to terms with is the lack
of care offered to Mispa simply on a human level. She was never consulted, only
told what to do and what not to do.... No one tended to her basic needs for food
or fluids or inquired if she needed to go to the toilet. It was as if Mispa, the
embodied person, did not exist. (Byford, 1999:186-190)
Unfortunately, this description is all too typical of hospital births
in the developing world. Byford's dissertation describes the general
poor health of rural Papuan women, who suffer from overwork, exhaustion,
anemia, malnutrition, and a variety of diseases that result from their
lack of access to clean water. She discusses research in public health
which shows that the single most important intervention that colonial
health services could have brought to PNG would have been an adequate
clean water supply. But biomedicine, here as elsewhere, prevailed, and
instead of investing in clean water, PNG invested in doctors and hospitals
in the cities, and rural clinics like the one Julia describes above,
which themselves do not even have running water most days of the week.
This biomedical approach to health makes it appear that problems inhere
in individuals and should be treated on an individual basis, patient
by patient, hospital by hospital, obscuring the fact that the major
causes of disease and death, among parturient women as among the general
population, are structural and will benefit far more from large-scale
systemic change than from diverting money into hospitals and clinics.
Given the difficulty of reaching the hospital and the poor treatment
they receive once they get there, most rural Papuan women still choose
to deliver at home—a trend paralleled around the developing world
as rural women, disillusioned with clinics and hospitals, return to
their community midwives and traditional birthways, leaving development
planners to shake, their heads over this unaccountable unwillingness
to use modern facilities, attributing it to ignorance and close-mindedness.
On the contrary, birthing at home with a traditional midwife is often
a considered decision that women make after weighing the risks and benefits
of their options. For example, Morsy (1995:168) notes:
In villages of the Nile Delta, although modem medical facilities
are available, women prefer to deliver at home with the assistance of a local
midwife. This choice is not a result of reified "cultural attitudes"
but a measured judgment about the inadequate health care extended to peasants
and the urban poor in modem-health care settings.
Anthropologist Denise Roth has described this process of "measured
judgment" in detail in her forthcoming book Bodily Risks, Spiritual
Risks: Contrasting Discourses on Pregnancy in a Rural Tanzanian Community.
Policy planners on high decided that each Tanzanian mother should have
and be in charge of a card documenting the prenatal care she had received
and her health and pregnancy condition. To make sure she carried the
card, it was decided that she would have to show it in order to be admitted
into the local clinic for labor and birth. In the city and small town
Roth studied, this confronted each pregnant woman with a difficult decision:
should she obtain prenatal care, which was costly, time-consuming, and
often inadequate, in case she needed to go to the clinic during labor,
or should she cast her lot with the traditional midwife, who was inexpensive
and kind but would be unable to take her to the clinic without the card?
Not surprisingly, many women after careful reflection chose the latter
option; of course, if they then had problems during labor but could
not go to the clinic, the traditional midwife would be blamed for the
Certainly, as Roger and Patricia Jeffrey pointed out in 1993, it is
important not to romanticize indigenous midwifery and indigenous midwives;
not all of them are skilled, not all of them give women good care; and
some indigenous customs can be as harmful as many obstetric procedures.
Those anthropologists most concerned about over-romanticization of the
traditional midwife, including the Jeffreys, usually study birth in
countries like India and Bangladesh, where women's status is very low.
In a recent cross-national study, Shen and Williamson point out that
low status for women directly correlates with higher maternal mortality
rates. Where women's status is low, their nutrition is poor, their overall
health is poor, and community midwives are less able to develop effective
knowledge systems, as Rosario (1998) and others have shown. Where women's
status is higher, community midwives are often able to develop long-standing
and viable systems of indigenous knowledge about birth, as indicated
in the growing body of ethnographic literature I cite in this article.
This literature consistently indicates that community midwives (TBAs)
usually give skilled and considerate care and remain, in many parts
of the world, the only viable option for millions of women. As an anthropologist,
I question the wisdom of dividing professional midwives and TBAs in
this hierarchical, biomedically oriented way which allows government
agencies and development planners to support one group while trying
to exterminate the other. Can't a "real midwife" either be
recognized by her government or by her community as such?
In sum, the present policy of separating professional from traditional
or community midwives has led to midwives' integration into a hierarchical,
intensely colonialist system that has doctors at the top, professional
midwives in the middle, and community midwives at the bottom, with no
power and very little government support. In this system, doctors have
most of the power. Professional midwives, who are usually biomedically
trained, often buy into this hierarchy, and work to impose biomedical
models of birth on indigenous populations—a situation Australian midwife
Leslie Barclay calls "midwifery hegemony." The surest sign
that such a system is in operation is when women who have birthed upright
for countless generations are suddenly told by the midwife or doctor
to lie down. Countless pages of scientific evidence now document the
efficacy and superiority of upright positions for birth! Yet biomedicine
in its arrogance insists that its way is best, and around the world
is still working to eliminate the few remaining viable indigenous systems
of birth, teaching even community midwives to make women lie down for
birth, and replacing home with hospital wherever possible.
In rural Thailand, for example, anthropologist Andrea Whittaker (1999)
is documenting the escalating biomedicalization of birth. As more and
more rural women spend large sums of money to have the more prestigious
hospital births, the community midwife's role is being reduced to postpartum
care. Ironically, at the same time as indigenous birthways are rapidly
vanishing in the rural areas, in Thai cities, where birth has long been
biomedicalized, an incipient alternative birth movement finds some professional
midwives beginning to attend the births of middle-class women at home
(Andrea Robertson, personal communication).
In the words of songwriter Joni Mitchell, "Don't it always seem
to go, that you don't know what you've got till it's gone?" Must
we lose the viable indigenous birthways that still exist before we rediscover
how valuable many of them were? Must the professionalization of midwifery
mean its colonization by biomedicine? Or can professional midwives reclaim
their autonomy, foster the globalization of the midwifery model of care
in culturally sensitive ways, work in tandem and cooperation with traditional
midwives, and become worldwide the agents of mutual accommodation and
Robbie Davis-Floyd, PhD, is a Research Fellow in the Department of Anthropology at the University of Texas, Austin. She is author of Birth
as an American Rite of Passage (1992), coauthor of From
Doctor to Healer: The Transformative Journey (1998) and has written and edited
numerous other books and articles. She lectures nationally and internationally,
and is currently at work on Mainstreaming Midwives: The Politics of Change.
References Cited and Suggested Reading
- Asowa-Omorodion, Francisca I. (1997). Women's perceptions of the complications
of pregnancy and childbirth in two Esan communities, Edo State, Nigeria. Social
Science and Medicine 44: 1817-1824.
- Barclay, Leslie M. (1998). Midwifery in Australia
and surrounding regions: Dilemmas, debates, and developments. Reproductive Health
Matters 6(11): 149-155.
- Barnes-Josiah, Debora; Myntti, C. & Augustin, A. (1998). The three delays as
a framework for examining maternal mortality in Haiti. Social Science and Medicine
- Byford, Julia. (1999). Dealing with Death Beginning with Birth: Women's Health
and Childbirth on Misima Island, Papua New Guinea. PhD dissertation, Dept. of Anthropology,
Australian National University.
- Davis-Floyd, Robbie & Sargent, Carolyn. (1997). Childbirth
and Authoritative Knowledge: CrossCultural Perspectives. Berkeley: University
of California Press.
- Graham, Sally. (1999). Traditional Birth Attendants in Karamoja, Uganda. PhD
dissertation, South Bank University.
- Jeffery, Roger & Jeffery, Patricia M. (1993). Traditional birth attendants in
rural North India: The social organization of childbearing. In S. Lindenbaum & M.
Lock (Eds), Knowledge, Power, and Practice: The Anthropology of Medicine in Everyday
Life, pp. 7-31. Berkeley and London: University of California Press.
- Jordan, Brigitte. (1993 ) Birth
in Four Cultures: A Cross-Cultural Investigation of Childbirth in Yucatan, Holland,
Sweden and the United States. (4th ed.) Prospect Heights, Ill: Waveland Press.
- Kolenda, Pauline. (1998). Fewer deaths, fewer births. Manushi 105 : 5-13.
- Morsy, Soheir. (1995). Deadly reproduction among Egyptian women: Maternal mortality
and the medicalization of population control. In F. Ginsburg and R. Rapp (Eds),
the New World Order: The Global Politics of Reproduction, pp. 162-176. Berkeley:
University of California Press.
- Rosario, Santi. (1998). The dai and the doctor: Discourses on women's reproductive
health in rural Bangladesh. In
Maternities and Modernities: Colonial and Post-Colonial Experiences in Asia and
the Pacific, pp. 144-176. Cambridge UK: Cambridge University Press.
- Roth, Denise. (2000). Bodily Risks, Spiritual Risks: Contrasting Discourses on
Pregnancy in a Rural Tanzanian Community. Ann Arbor: University of Michigan Press.
- Shen, Ce & Williamson, John B. (1999). Maternal mortality, women's status, and
economic dependency in less developed countries: A crossnational analysis. Social
Science and Medicine 49: 197-214.
- Whittaker, Andrea. (1999) "Birth and the Postpartum in Northeast Thailand: Contesting
Modernity and Tradition," Medical Anthropology 18(3): 215-242.
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