Learning from Successful Intercultural Midwifery Models of Care: From Summer MPH internship at Centro Osa Mayor in Tulum, México to the Ecuadorian Amazon

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Student Research Reports, Summer 2017

 

Learning from Successful Intercultural Midwifery Models of Care: From Summer MPH internship at Centro Osa Mayor in Tulum, México to the Ecuadorian Amazon

Robin Fink


Abstract:

For approximately twelve weeks, I have worked as a graduate student intern at the Centro de Parto Osa Mayor in Tulum, Mexico. The purpose of this project was to develop a comprehensive understanding of what a successful model of an intercultural midwifery clinic looks like in Mexico, in order to explore the possibility of applying something similar in the Ecuadorian Amazon. I have worked on indigenous health issues in Ecuador and Peru since 2006 as an anthropologist, program director, and Maternal and Child Health consultant. In the Centro, I co-developed a midwifery skills assessment for mix-literacy level midwifery students, developed and executed a midwifery leadership training workshops, worked with Osa Mayor director and the Vice President of the Midwifery Association of Mexico (AMP) to develop advocacy tools for their midwifery certification program, and facilitated conversations with midwifery students and Osa Mayor staff about expanding Osa Mayor into a larger birth center and midwifery teaching school. Lessons learned: conversations currently being undertaken in the field of Maternal and Child Health and Global Health need to extend beyond simply treating maternal and infant mortality as a priority. We need to focus on improving the quality of care and the quality of life that women and their families have access to. The use of the findings of this research will not only be useful in order to promote more spaces for indigenous midwifery in Ecuador, but there is much important, evidence-based work happening within the context of the midwifery model of care in Mexico that has the potential to significantly impact the sphere of global health and maternal health. Too many interventions originate from the Northern Hemisphere and both western medicine and midwifery have lot to learn from indigenous, traditional, and non-traditional midwives in Latin America. 

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As a recipient of the 2017 Tinker Summer Research Grant Award through the Center of Latin American Studies, I traveled to the Mexican state of Quintana Roo at the Osa Mayor Birth Center located in the coastal town of Tulum. For the last eleven years, I have worked in various capacities in indigenous health programs in the Ecuadorian Andes and Amazon regions. For the last eight years, I have worked with indigenous women on a maternal and child health program, Ikiama Nukuri (Women and Mothers as Defenders of the Forest) in the Ecuadorian Amazon. As a Masters student at the UC Berkeley School of public health, my primary purpose of being in Quintana Roo was to develop an understanding of what a successful model of an intercultural birth house looks like in Mexico, in order to explore the possibility of applying something similar in the Ecuadorian Amazon.

Osa Mayor is both a birth center and a movement founded by Sabrina Speich, the current Vice President of the Mexican Midwifery Association (AMP). Osa Mayor works to provide “a holistic and evidence-based model of care in all of the phases of pregnancy, birth, post-partum, nursing, integrating traditional Mayan techniques and practices with principles and values that are respect for mothers and infants. This model of care is matri-focal, in that it focuses on the autonomy of the mother and promoting balance among body, mind, and spirit. Since 2008, Tulum’s population size has nearly tripled,  due large in part to its rapidly growing tourism industry. Migrant workers from all around Mexico come to Tulum seeking employment in construction and tourism and foreigners, primarily from other Latin American countries and Europe, also seeking employment and opportunities for an “alternative” lifestyle. As a result, the population that Osa Mayor serves is highly diverse, with its clients being primarily indigenous Mayan women, Mexican mestizas, and foreigners. 

 

Osa Mayor Leadership (Photo by Robin Fink.)

Robin Fink, MPH '18, with the team of Osa Mayor Birth Center, after having completed a midwifery leadership training workshop, lead by Fink. Fink developed this workshop based on conversations with all of the team members, including my Achuar colleague from Ecuador. Each person, specifically the clinic director, identified particular areas where each person felt like they needed leadership-building in effort to more effectively deliver care and to feel more empowered doing so among a diverse client population.

 

Osa Mayor is completely run by women and built into its structure are spaces for members of the community, including men, to come together and discuss the needs of the community and population. The staff at Osa Mayor is highly diverse, with midwives and apprentices ranging from the United States, Switzerland, Mexico, and Ecuador, over half of whom are indigenous. While working at Osa Mayor, I learned the importance of having midwives and healthcare providers representing the communities they serve and building an understanding of cultural difference and inclusion into their model of care. Osa Mayor not only provides services such as prenatal, birth, and postpartum care, but also creates spaces in which women and mothers are the primary focus, or what the birth center refers to as matricentral spaces. 

Global Maternal and Child Health interventions working to reduce infant and maternal mortality must extend beyond the institutionalization of birth and recognize the important roles that both professional and traditional midwives play in providing care for women and their communities. Efforts should be made focus on improving the quality of care and the quality of life that women and their families have access to. An example of where this occurs is through the training and education of midwives and Mexico is an excellent example of how to achieve this. The Mexican Association of Midwifery has a lot to show for how it works to include traditional midwives into the process of certification. 

Osa Mayor serves as a unique example of how to serve mothers from diverse back grounds by making their services available on a sliding scale. Women who are more structurally vulnerable than others pay for their services based on a sliding scale. Of these include the Tribu Pancitas prenatal meeting groups. At these meetings, a safe space is created for (expectant) mothers and midwives to talk about health, pregnancy, birth, life, knowledge, and areas of self and group empowerment. While the midwives also provide their clients with regular prenatal care, these groups work to foster community and sisterhood. A component of my work at Osa was to work with the team to co-develop methods and a system for evaluating mothers’ experience during their prenatal, birth, and post-partum time at Osa. Additionally, a part of my work was to help develop a theoretical framework for Osa midwives to address behavioral health of mothers during pregnancy in effort to provide improved care. Issues of how to midwives can better address expectant mothers’ experiences of domestic violence and/or discrimination was a topic of great importance, especially given that Tulum is a town where both a history of colonialism and the tourism industry has created a context for great inequities. 

Unlike many countries, Mexico’s Ministry of Health (Secretaría de Salud) has made an effort to work with both traditional and non-traditional midwives. I had the opportunity to accompany the Osa Mayor team to attend monthly continuing education workshops and turn in their birth registries. Having come from a context in Ecuador where the Ministry of Health has yet to take on a national program to collaborate and work with traditional midwives, Mexico’s approach seemed to me quite innovative and much can be learned. However, what I see as generally lacking is an approach that views both traditional and professional midwives as co-creators and collaborators in the creation of birth knowledge and practice. While this process of inclusion is unique for many health ministries in Latin America, it still falls short in that it produces a linear transmission of knowledge, originating from the ministry of health and ending in the midwives who attend the workshops. This process, termed by Eduardo Menendez as, the hegemonic medical model,  only considers authoritative health knowledge creation as it originates from western medicine and from institutions, whereas midwives are seen as not possessing of health knowledge. It is this process that has produced a rich site for discussion and innovation in care, that both Osa Mayor birth center and the Mexican Midwifery Association have been working hard to address. 

 

Osa Mayor Workshop

The midwifery apprentice from the Ecuadorian Amazon explains how the body of the mother changes during pregnancy to Osa Mayor director and teacher.

 

Midwives continue to play an important role in providing care to marginalized women. The Mexican Midwifery Association is currently working on a midwifery certification program that works to incorporate both professional and traditional midwives into the system in effort to recognize the important role that midwives play in caring for the health of women, infants, and communities. Promoting spaces that allow women and midwives come together and support each other are very valuable for improving quality of care. Learning from the expertise of midwives and leaders throughout Mexico will be crucial to collectively and creatively vision futures for indigenous models of healthcare in the Amazon and beyond. 

 

1.  “Doce mil personas al año ‘llegan para quedarse’ en Tulum.” SIPSE. 24 Feb 2015. http://sipse.com/novedades/se-establecen-en-tulum-12-mil-personas-al-ano.... Accessed: 20 Aug 2017.

2. Menéndez E. El modelo médico y la salud de los trabajadores (The Medical Model and Worker’s Health) Salud Colectiva. 2005;1(1):9–32.

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