Home versus the hospital: Negotiating birth location risk and midwifery’s value in Mexico

As residents of the Mexican state of Quintana Roo began to adopt social distancing practices and hospitals and clinics emptied of their usual patients in preparation for providing COVID-19 treatment in March and early April, home-birth midwives saw a surge in demand for their services. In Mexico, between 93 and 98% of births normally occur in institutional settings, and midwives — particularly traditional midwives — have seen a steep decline in clients since the implementation of the public insurance program Seguro Popular in 2003. Seguro Popular provided a suite of free prenatal and maternal health services to program beneficiaries, and the sudden, near-universal accessibility of these services led to a decline in homebirths because midwifery services were not covered by public insurance. However, since the pandemic began, home-birth midwives—both traditional and certified—have been inundated by requests for assistance and birth attendance from pregnant women who now view hospitals and doctors as vectors of contagion or have been frustrated by cancelled appointments and decreased quality of care. In Quintana Roo’s public hospitals, women continue to labor in wards alongside dozens of others, with few, if any, COVID-19 prevention protocols in place. This state of affairs has pushed many to seek out midwifery care for the first time.

This is not only a reversal of the decades-long pattern of decreasing rates of home-births but also a sudden reversal of broader public perceptions of risk and risky choices in birth. Midwives of all types who practice home-births—professional midwives trained and certified in a biomedical model of care and traditional (usually Indigenous) midwives, who tend to learn midwifery in an apprenticeship model—have often been denigrated by physicians, public health officials, and the news media in Mexico as “primitive,” “dangerous,” and “unsafe” practitioners and/or as the living vestiges of dying Indigenous cultural traditions. In neither framing is their work acknowledged as clinically efficacious or a valuable contribution to public health. While midwifery is constitutionally protected as an Indigenous tradition and thus cannot be explicitly banned, many state Ministries of Health have developed protocols for registering births and obtaining birth certificates that have made it nearly impossible for professional and traditional midwives or their clients to pursue home deliveries. Even in states that appear to be more midwifery-friendly, similar bureaucratic processes and hostile attitudes from hospitals and physicians make practice “risky” for home-birth midwives, who cannot depend on medical institutions to coordinate client care or be available as support in case of emergency. This lack of support also creates conditions in which midwifery care becomes riskier for clients.

It is in this context of low and even absent state support for midwifery that the increasing shift of responsibility of care for pregnant women, from public medical institutions to midwives, is particularly poignant. Some midwives report that they are now receiving more requests for services than they can accommodate. The calls come from women in all stages of pregnancy, including after labor pains have already begun. In particular, low-income and Indigenous Maya women are flocking back to midwifery care, despite their nominal coverage by public insurance. With the collapse of the tourist industry along the Maya Riviera, formerly middle-class clients are now unemployed and require free or reduced fee midwifery services as well. While the quantity of clients is partially making up for the limited fees individual clients can pay, demand for pro bono care is increasing. Midwifery’s sudden shift back into favor is marked by clients’ assessment of risks, fears of abandonment by medical institutions overwhelmed by COVID-19 —or the threat of COVID-19—and attempts to navigate the complicated and frightening terrain of the pandemic, where economic precarity must be weighed against health risks.

Public insurance beneficiaries’ heightened concerns about their safety and the quality of medical care they will receive as the healthcare system grapples with the challenges of continuing to provide normal medical services and treat COVID-19 patients has manifested in a crisis of confidence and avoidance of clinics, even in emergencies. After decades in which public health institutions in Mexico have viewed midwifery as a dying practice and have thus not supported training and promoting the next generation of midwives, most currently practicing midwives are older and have chronic illnesses that render them particularly vulnerable to COVID-19 infection. Thus, the available pool of midwives is even smaller at the time when there is greatest need.

In Quintana Roo, instances of families choosing to birth without any skilled assistance—midwives or physicians—have jumped dramatically, most commonly in contexts where families viewed hospitals as too risky due to COVID-19 but couldn’t find or afford a midwife to attend their home-birth. In these cases, the perception of risk of contracting COVID-19 in medical institutions—already distrusted by many in the country due to their underfunded state and crumbling infrastructures—outweighs the perceived risks of birthing alone, without medical support. Midwives and journalists drew attention to these issues in late April in the Mexican news media, and a flurry of positive press hailed midwives as bearers of ancestral knowledge and responsibility, stepping forward for their communities in a time of great need. Midwives also critiqued the Ministry of Health, both for the poor quality of care that women were receiving when they did birth in hospitals and for maintaining the bureaucratic barriers that make home-births so difficult for families and midwives to navigate.

Shortly after this, Ministries of Health and government representatives issued press releases and news articles emphasizing the safety of medical institutions and, specifically, urging pregnant women not to turn to midwifery or home-birth. In these public announcements, doctors and administrators of public institutions simultaneously asserted that their implementation of COVID-19 transmission prevention protocols rendered clinics and hospitals safe and that midwifery services were “very high risk” and a poor choice compared to care in hospitals. Despite these warnings, midwives have continued to field far more requests from pregnant women than they can accommodate. They express concerns that many of their would-be clients, even those who appear in the middle of the night already in labor, have not had prenatal care, prenatal tests or blood panels, or ultrasounds to check fetal development—steps that even the most traditional midwives usually require their clients to complete. For midwives, the lack of prenatal care is risky not just for mother and fetus but for themselves as well. Midwives bear the legal and professional risks should there be a complication or poor outcome, but in many cases they find themselves walking into births without knowledge about their clients’ health.

Midwifery’s return to popularity during the pandemic and the subsequent backlash from biomedical and public health institutions in Mexico highlight continued contestations of the safety and value of midwifery care. They also highlight the ongoing barriers to midwives’ professional legitimacy in the eyes of the state and the tensions around the legitimacy of public healthcare institutions in the eyes of the population. Healthcare institutions’ decreased capacity to meet the needs of pregnant and birthing women is of major concern to midwives and, increasingly, pregnant people and their families. In this context, it is particularly disappointing to Mexican midwives that the widespread public support and demand for their services have not motivated collaboration between state Ministries of Health and the midwives who are stepping forward to provide critical maternal health care.

In the absence of that support, midwives have created a national database of certified and traditional midwives, obstetric nurses, and obstetricians available to take on home-birth clients during the pandemic, in order to remove some of the barriers leading women to birth unassisted. While this is an important step, it cannot address the complexities of out-of-pocket services during a time of economic disaster. Nor are traditional and professional home-birth midwives themselves capable of reorganizing the maternal health system in such a way that reduces risks, addresses overcrowding and public perceptions of poor care, or ensures that all women continue to have access to critical prenatal care no matter their birth plans. Meeting these needs will require collaboration, and for state Ministries of Health to recognize and support the contributions of certified and traditional midwives to public health. Likewise, it is critical that the World Health Organization, in its “Year of the Nurse and Midwife,” take public steps to recognize and support the traditional/Indigenous midwifery as an existing workforce, and acknowledge their importance in filling crucial gaps in maternal health care systems. Only with support from the top will midwives’ grassroots work be able to meet demand.

Sarah A. Williams, M.A. is a PhD Candidate in medical anthropology and Fellow in the Collaborative Specialization in Global Health at Dalla Lana School of Public Health at the University of Toronto. Her doctoral research focused on maternal health and the politics of midwifery professionalization in Mexico. She is currently co-investigator of a project exploring the effects of the COVID-19 pandemic on sexual and gender minorities in Toronto. Sarah.williams@mail.utoronto.ca

Sabrina Speich is the director and founder of the Osa Mayor Midwifery School and Birth House in Quintana Roo. She is a former executive board member of the Mexican Association of Midwifery and was the founder of the initiation process for the certification of Mexican midwives. osamayortulum@gmail.com