Stories of Extraordinary Central American Midwives
by Marie Tyndall

[Editor's note: This article first appeared in Midwifery Today Issue 91, Autumn 2009.]
Photos provided by the author

From the 1970s to the 1990s, a series of long, violent and bloody civil wars in Nicaragua and El Salvador—against US-backed military forces—forced local people to take control of their lives in new ways. Conditions of extreme need and poverty were created by the constant threat of attack. Even in the so-called periods of ceasefire that brought “refuge” to the decade and a half of fighting, there were rifles in the streets, missiles firing, and bombs falling at any given time. So it was that the largely self-taught and traditional midwives of the region were needed to teach their skills, look after the sick, and of course, assist new life into this world. Many great women and men lost their lives serving their communities during these devastating wars and many of them were midwives.

In Central America, midwives don’t just attend births. They look after sick children; they clean and suture machete wounds; they teach family planning methods and give out condoms; they lend a hand to women enduring domestic violence; they support adolescent girls who find themselves pregnant; and they find food for hungry families. Around their kitchen tables, stories are told, advice is sought and given out, and hearts are mended. In short, it is often a selfless, wide-ranging, and anonymous mission to fill in a gap that is necessitated by living conditions and overlooked by the public health care services of their governments.

There is a truly authentic, mammalian sense of love among midwives in the region, and beyond that, an ardent sense of human rights that is often difficult to come across. I think more than anything it is these two virtues that characterize midwives working throughout Central America. In this short commentary, my hope is to share with you the lives and work of two midwives in the region who exemplify these virtues. Around these parts, they are well-known, loved and respected, and their stories deserve to be told.

Mama Licha, Nicaragua

Alicia del Carmen Huete Díaz, or Mama Licha

Alicia del Carmen Huete Díaz, or Mama Licha

Alicia del Carmen Huete Díaz, or Mama Licha, as she is affectionately known in Estelí, a town in the northern highlands of Nicaragua, is 74 years old. But you would never know it. She looks and acts much younger, despite a difficult life. She was the first person from an enormous family to learn to read and write, and when she was young and with children herself she became a teacher, working in schools in rural Nicaragua. As a young mother and teacher, Doña Alicia became sick with pneumonia and was hospitalized. During her hospital stay she was getting up and helping other patients, and this is how she discovered her desire to care for others. They hired her on the spot as an apprentice nurse, and she worked in the hospital for 15 years.

Doña Alicia collaborated to help bring about the 1979 revolution in Nicaragua by holding meetings in her house; two of her sons, aged 14 and 18 at the time, went on to serve as fighters in the Sandinista Revolution. While her sons would be gone for weeks on end, Doña Alicia worked in the hospital, sometimes for days without returning home to see her girls, who stayed with their grandmother. Doña Alicia’s collaboration with the political uprising had to be entirely secretive; she was interrogated and threatened with death repeatedly in the hospital, and one time la Guardia came to her home and proceeded to hold her and her children hostage while they ransacked the house looking for evidence of a Sandinista affiliation. She witnessed innocent friends and hospital colleagues being burned alive and is thankful to this day that she and her children escaped with their lives.

After the overthrow of Somoza in 1979, Alicia worked in the emergency department of the hospital; in this way she could support the revolutionary army. Alicia became the president of the Union of Health Workers. But even amongst hospital employees there were divisions. Not everyone supported the revolution. Dividing Nicaraguans was a principal strategy of the enemy, the Contra army assembled and supported by the US. Many Americans to this day may be astonished to know that former president Ronald Reagan trained and armed a powerful military machine with the intention of destroying the revolutionary government. But the revolutionary government made great strides in improving literacy and higher education, providing health care for all, alleviating poverty and hunger, and redistributing the land which had been held in the hands of the dictatorship and its rich associates. “It was an arduous battle at the cost of many heroes,” says Doña Alicia.

It was in 1989, when she was asked to work in the government-funded birth centre in Estelí, where she really discovered her true calling and passion. In her words: “I learned a lot at the birth centre, especially with the midwives. We say they have an encyclopedia in their heads. Most of them are illiterate, older—in their 60s or 70s, but they know a lot because they have seen a lot, not because they ever studied. I learned from them to have more love for other women, because when pregnant, women need attention, loving care, comprehension, and to be listened to. I also learned to value myself; I learned how to truly respect, care and earn the trust of others, to give them real love and support.”

“This was a year of a lot of work. We began holding workshops for all the midwives in the northern region who had never received any training. There were around 1000 midwives,” says Doña Alicia. “We would meet for one week and cover the topics of reproductive systems of men and women, pregnancy, clean birth, the puerperium, family planning methods and sexually transmitted diseases (STDs). The methodology was participative—there were sociodramas—and at the end each midwife received a birthkit and certificate and became registered. It was an exciting time; we held parties at the end of each training.

“The revolutionary government prioritized and invested in training midwives. Later we were sent all around the country holding workshops, at which 2000 midwives in all received training and follow-up and became registered.”

Doña Alicia worked in the birth centre in Estelí for 11 years. As well as holding monthly follow-up workshops for midwives from the surrounding countryside towns, Mama Licha gave prenatal courses and consultations, provided well-woman care and attended births. When she “retired” reluctantly at the age of 64, she said she couldn’t live without her panzonas, or pregnant ladies, and even less so without her viejitas, the midwives who contributed so much to her educational and spiritual growth.

By then a lot of women depended on the loving attention of Doña Alicia, and they simply went to her house. She continued to give prenatal care and preparation classes, hand out contraceptives and attend births in her house. She was filling a need in the community for a special place for women to find comfort and for a person who listens and treats them with respect, kindness and love. Alicia’s daughter Karen recounts, “Alicia was reborn when she was able to continue her work from her house, because her work as a partera is what gives her the most satisfaction.” With inadequate space in her humble house, little by little Doña Alicia received enough financial assistance to build a birth centre in her back yard.

The birth centre has two spaces: a birthing room and a teaching room with a television and DVD player, books, brochures and magazines, for childbirth education courses as well as for teaching students and health personnel.

Alicia’s work also includes travelling to tobacco factories in the region to give talks about reproductive health, pregnancy and STDs. In the clinic she does PAP smears, pregnancy tests and colposcopies, free of charge. A nongovernmental organization (NGO), Juntos Adelante, donated a colposcope and was the primary support behind the building of the centre. Birth control and antibiotics are also distributed free of charge.

“The worst problem that the women face here is HPV [human papillomavirus]. They are young and poor, victims of machismo, and the men take no responsibility and, what’s more, blame the women for contracting the virus. At the clinic we try to raise awareness and convince both women and men of the importance of being informed and of prevention and detection of this disease.”

The clinic runs on a very tight budget and Alicia does everything. “We need to be able to pay an additional health worker to carry out all of Alicia’s activities in the clinic and around the country, and we need more space too,” says Alicia’s daughter Karen.

Each month, Doña Alicia travels with a health brigade of 60 to 90 volunteer health workers to remote areas of Nicaragua where there is no health care. Many specialists go and in each community they visit, they see each and every person, young and old. Doña Alicia does all of the PAPs, which are processed immediately, and when abnormal cells are identified colposcopy is done on the spot and medicines are handed out free of charge. This type of service is typical in Nicaragua and has its roots in the revolution. Another example of Alicia’s revolutionary spirit: “Out in one community last year I broke my ankle, but it doesn’t matter. Everything done with love, and for those in need, is worthwhile.”

Doña Alicia continues to work with traditional midwives throughout the region in monthly training sessions at her centre. As well as expanding midwifery knowledge, the midwives have become community organizers and have varied responsibilities, including selecting three people from their villages to analyze the health issues particular to their community and recording that information, which includes births and maternal and perinatal mortalities, and then sending that to the Ministry of Health. Each village has a fund for emergencies that the midwives manage. On a map they mark where all pregnant women are, and they refer high-risk pregnancies to a birth or health centre. They also teach about family planning methods and refer women to centres where they are available.

Doña Alicia provides materials that the midwives need to restock their birthkits. “What the midwives need at the moment are eyeglasses for poor vision, raincoats, flashlights, rubber boots, scissors, plastics sheets to cover beds, cord ties or clamps and antiseptic solutions,” Alicia reports.

If you’d like to learn more about Alicia’s clinic or make a donation, go to www.mamasclinic.org.

Doña Josefa Mira, El Salvador

Celina Estella Martínez, Josefa Mira and Edie Arely Martínez

Celina Estella Martínez, Josefa Mira and Edie Arely Martínez

Josefa Mira was also born into an extremely poor family, and with many sisters and brothers her parents told her that education wasn’t a possibility, much less a priority. From the age of eight, Josefa taught herself to read and write, and she is now one of the most respected midwives in El Salvador. In addition, she provides medical care to people of all ages and works daily as an advocate for women’s rights.

Josefa gave birth to the first of her fourteen children with only her grandmother in attendance when she was just fifteen years old. “Nobody went to the hospital back then, you just took care of yourself and each other.” After the second child she gave birth to the other twelve alone.

She was pregnant with her fourth child when her younger sister went into labor. When her sister came to her for help, Josefa was hesitant. She says, “I didn’t have any experience, other than my own births, but I just helped her while she labored and the birth went fine and there was no trouble delivering the placenta.”

“I’ve been a midwife since 1960; it was simply out of necessity. In those times, women didn’t go to clinics; we all had our babies in our homes. Women put their faith and trust in me and I was the midwife of all of the women of our community. But no one called me a midwife; not even I called myself a midwife. The women sought me out as an intimate friend to accompany them during their deliveries, and I stayed with each one until the baby was safely born, the house was tidied up, and the bed clothes were washed. And then they’d say to me, ‘You can go, chepa (a term of endearment), thanks for everything.’”

Josefa helped deliver babies during 12 long years of war in El Salvador. The people of El Salvador lived under a state of siege and no one dared travel to a hospital; they were filled with war victims and the risks of travelling from the countryside to the city were too great. Josefa attended births in fields or makeshift dwellings, everywhere they happened to occur.

Just like Alicia, Josefa has known the anguish of being a mother with young children during years of war. Josefa gave birth to her youngest daughter when she was forty-five. She was living in a town called Santa Clara at the time with her five youngest children, and she left a week before she was due to give birth. She and the children walked down along the river bed and back below the road from Santa Clara because they knew it was more dangerous to travel along the street. It was on this day, as they hiked through the woods below the road, that the military marched above them into Santa Clara and massacred all 150 children of the village. Her own children are only alive because they left with her for the birth of their sister Sara.

All of Josefa’s boys were soldiers for the FMLN, the revolutionary army. During the war Josefa had her older children living with their father and her younger ones with her. She had to travel back and forth through the most violent area in the country between the two families. The bus would often be attacked or bombed by helicopters, and Josefa escaped death many times. She can laugh now as she recalls her older children fighting in the war, with just a hand grenade to protect themselves. Because they were fighting against fighter jets, a grenade couldn’t do anything! But there was a long time when she was unable to look back at the war and tell stories and laugh.

After the war ended so many people were traumatized that no one would talk about it, and some people couldn’t talk at all. Josefa was among them. She gives full credit for her post-war recovery to Las Dignas, a feminist NGO that has been working in El Salvador for 20 years. They offered psychological support and trained mediators to help get conversation started and remind the women that it is okay to smile, laugh and cry. Josefa says that there was no program like this for men. “They hold everything inside. That is why they are so violent and don’t know what to do with themselves; they are still reliving the war.”

In 1994, after the war ended, women of the community and Las Dignas sought financing to form the birth centre in Talpetates. They immediately contacted Doña Josefa to come and work in the centre and to formalize her training as a midwife. At this time Josefa started to refer to herself and be referred to as a “midwife.” The centre serves the 14 communities that are part of Las Talpetates, Berlín Municipality, and Usulután, serving mostly women, but also children and men. It was inaugurated in April of 1997.

In the early years, Josefa and her team attended about 200 births per year, but thanks to the centre’s family planning and teen counseling program, that number is down to about 50.

At the Casa Materna in Los Talpetates, two younger nurse-midwives work alongside Josefa. They too learned out of necessity during the war and have since taken courses to learn specific skills like suturing and inserting IVs. Edie Arely Martínez is 35 years old and has two children herself. She became a nurse during the war when she was 12 and is very skilled at suturing. Celina Estella Martínez is also 35 years old, has four children and is called on to insert IVs and give injections.

The Casa Materna is the general health clinic of the community. They commonly treat respiratory problems and a variety of infections, including STDs. They do prenatal care, including providing prenatal vitamins, and give out contraceptive devices including Depo-Provera shots, birth control pills and condoms. They treat a variety of cuts and wounds, since the sugar cane harvest season brings in a lot of machete wounds. They have antibiotics available for infections and offer vitamin B12 injections to women suffering from extreme fatigue, often parasite-related. Intravenous hydration therapy is offered for heat stroke and dehydration and they can set and splint broken bones. They have a truck to transport more difficult cases to the hospital, two hours away. They also give talks about STDs and HIV and offer psychological and legal aid and support for abused women and children.

The community of Talapetates is extremely poor. Machete wounds are common because men, women and children work 15-hour days in the sugar cane fields to make three dollars per day. At the clinic, they treat children who have collapsed from not eating for days or from parasitic, bacterial or viral infections from drinking contaminated water.

The Casa Materna is equipped only with the most basic of materials and they need many things: local anesthesia, suture material, IV sets, Pitocin and other meds to handle obstetric emergencies, and medications for general medicine. They also are soliciting a wheelchair. Finally, daily operating costs are not covered by the only financial aid they have, which comes from a church group in Kansas and only includes a small salary for the nurse-midwives. They have to charge for some services, e.g., a birth costs $12, but they do not charge anything for most of their services and what they do charge does not cover their costs.

Josefa is now 72 years old. She is the mother of 14 children, 10 living and four dead, and has 45 grandchildren, 26 great-grandchildren and one great-great-grandchild. She lives with three of her children and six grandchildren, between the ages of three and nineteen. Josefa has attended births for over 50 years and even at the age of 72 she has no plans for stopping. The most amazing thing about Doña Josefa is her incredible personality, optimism, joyfulness and spontaneity. This is something that can’t fully be conveyed in an article; you really have to meet Josefa and experience firsthand her remarkable kindness and warmth. It’s what we midwives recognize as the “midwife’s heart.”

If you’d like to support the work of Doña Josefa, contact Mamasol Asociation, or Hope Jackson and the Educate El Salvador project through their Web site at www.educateelsalvador.org.

Marie Tyndall is a Canadian midwife who has been working in Central America for 15 years. She resides in Costa Rica and is a country contact for Midwifery Today. In 2004 she made a short film about midwives in Central America (www.central-american-midwives.org), and she founded an NGO called Mamasol in Costa Rica for the humanization of childbirth (www.mamasol.com).


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