Mari Cruz Coronado Saldierna has been a working midwife in Mexico for 24 years. She grew up in a rural area alongside her 14 brothers, and now serves remote communities just like the one in which she was raised, supporting vulnerable women and children living amongst sexism, alcoholism, prostitution, violence and social injustice. “I have always felt like my vocation is to be of service—to everyone but, above all, to women,” she says. “I want to work with and for women and their families during moments of profound change, and help them with that process.”
Saldierna used to be the director of a midwifery school in the mountainous Guerrero region, where primary healthcare services are restricted to the most developed areas, making them inaccessible to the general population. She spent her days walking for hours along dirt roads to make home visits to expectant or new mothers, along with the students she was training. Now, Saldierna works in a small town in the state of Guanajuato, offering pre- and post-partum consultations, assisting during labor and supporting other healthcare needs such as cancer screenings, as well as training other aspiring midwives.
Bridging the gap between healthcare systems and Indigenous communities
Often, Saldierna’s work involves combining traditional knowledge with more modern methods of care in order to earn the trust and respect of the communities she serves. “Once, I was assisting a local midwife during a tough birth when the girl started hemorrhaging,” she recalls. “I begged her parents to allow me to transfer her to a hospital but they refused to do so unless the local midwife told them it was necessary. Eventually I found a medical solution they would accept and the local midwife continued to administer traditional treatments, too. I realized how much trust people have in traditional midwives and how that trust has a significant impact on the health of women in these rural communities.”
Midwives like Saldierna provide a vital link between the primary healthcare system and Indigenous populations. In Mexico there are almost 12 million Indigenous people divided into 64 Indigenous groups many of whom live in remote communities with limited access to maternal health services.
Carolina Guantes believes that many of these vulnerable women are unaware that they deserve to be treated with more respect. Having originally trained as a midwife in Spain, Guantes moved to Colombia after meeting her future husband. In Colombia, there are nearly two million Indigenous people, divided into 106 Indigenous groups, and maternal and neonatal mortality amongst Indigenous peoples is up to five times higher than the national average.
“In the communities where I work, many women are in the dark about their basic sexual and reproductive rights,” says Guantes. “Empowering them to understand these rights and insist that they be upheld would positively affect everything from maternal mortality rates to child and teen pregnancy rates to the risks imposed by institutional violence in obstetric care.”
Fighting for professional relevance and recognition
Midwives across Latin America are key to ensuring health outcomes for mothers, newborns and children. However, like many frontline health workers, they often lack the training, resources and ongoing support to best serve their communities, especially in remote and rural areas. This partly stems from the fact that midwifery is not recognized as a formal profession in many Latin American countries, something which has a significant impact on the midwives’ capacity and therefore on the lives of the women and families they serve.
Formally-trained midwives have been acknowledged as professionals by the state in Mexico since 2011, yet in many places there is still a gap between this theoretical recognition and their treatment in practice. “We’re often not able to practice midwifery to the best of our abilities because the guidelines aren’t always aligned with our practices,” says Saldierna. “We don’t often have the freedom and autonomy to work like any healthcare professional and because of this we are often put in roles that don’t match our skillset, with lower salaries than we deserve.”
The Johnson & Johnson Foundation partnered with UNFPA in 2017 to strengthen and elevate Mexico’s midwifery workforce, starting with addressing gaps in pre-service education. The program built a network of universities and hospitals to implement midwifery training in line with recommendations from the International Confederation of Midwives and backed by the Ministry of Education and the Ministry of Health. The program aims to provide these professionally certified midwives a direct entry into the health services upon graduation, to provide not just assistance at birth, but a continuum of care from preconception and anti-conception consultations, labor and delivery, post-natal care to women and babies, and adolescent health and development.
In 2020, the Johnson & Johnson Center for Health Worker Innovation collaborated with UNFPA to expand the midwifery program to Brazil and Colombia, and in 2021 in Argentina. Each country program, while developed from the basic competency framework, is tailored to meet local needs in the different regional contexts.
Guantes has been working for the past two years with UNFPA to advance formal negotiations around the formalization of midwifery in Colombia. “This would dramatically lower certain indicators like maternal and newborn mortality ratios, as well as helping to prevent accidental pregnancy and resolve unmet contraceptive needs,” she says.
A new generation of midwives
Studying midwifery in a registered institution is expensive in many Latin American countries—yet official accreditation is important to allow midwives to operate efficiently alongside other primary health services. Many women can only afford to study with financial support. “I studied to become a professional midwife thanks to a complete scholarship,” says Saldierna. “The scholarship was an amazing opportunity for me. I’m married with four children, so it took a lot of effort to change the direction of my life—but it has been worth it.”
Now, Saldierna is supporting other young women to transform their lives via midwifery training. “I have seen Indigenous girls—whose destiny was early marriage—transform their lives bit by bit as they train to become professional midwives. I have watched as they fall in love with this career and bring out the best in themselves.”
A new generation of young women are keen to join the profession, support women in their communities and fight for respect and recognition for the work midwives do. 24-year-old Aida Xicotencatl Franco is currently studying Reproductive Health & Midwifery at the Universidad Technológica de Tulancingo based in Hidalgo, Mexico, combining online lectures with practical experience at the local hospital. “My biggest motivation is knowing that I’ll be able to be of service to my community and use my knowledge to improve the quality of life there,” she says. “When we’re passionate about what we do and stay positive, I believe we can overcome any obstacle. But also, we need to know we’ll be compensated for our knowledge and experience.”
Guantes, too, is inspired by how small actions as a midwife can have a significant impact. “It’s gratifying to receive messages of support and gratitude for your work and you know you’re making a difference to these communities. This is how you plant a seed and watch it blossom on its own.”