blog — March 07

Excerpt - Guardianas: Dispatches from the Association of Midwives Rosa Andrade

Guardianas is a bilingual collection of testimonies from midwives in El Salvador who delivered babies during the twelve-year-long civil war and who, today, fight to protect their ancestral role in the midst of ongoing repression.

This edition includes thirty color photographs and five black-and-white illustrations.

Out of necessity, women in El Salvador began attending births during the twelve-year-long civil war, when pregnant people in rural areas and guerrilla camps could not access medical care. From their mothers and older midwives, these women learned partería—traditional midwifery that was once the norm in El Salvador and has since been prohibited. After the official end to the war, the parteras became central fixtures in the “repopulation” of their country, building new communities, often without electricity or running water or hospitals. In 1994, out of this organizing, the Association of Parteras Rosa Andrade (APRA) was born. Today, the founding members of APRA, along with a younger generation training with them, continue to fight for the reproductive rights of thousands of people living in the municipalities of Suchitoto, Cuscatlán.

Collected in 2019 by Salvadoran American birth worker Noemí Delgado, Guardianas weaves together testimonies from twenty members of APRA to tell a collective story of:

- the experiences of midwives, mothers, guerrilla fighters and “gente de masa” during the armed conflict that took approximately 75,000 lives; 

- the role of the midwife during the period of repopulation after the signing of the Chapultepec Peace Accords, when thousands of displaced Salvadorans were finally allowed back into their homeland;

- the brutal obstetric violence that people giving birth in hospitals routinely face, and how this mistreatment compares to care provided by a midwife; 

- the extreme repression Salvadoran midwives have faced since 2011, when the health ministry prohibited home births;

- the ancestral nature of partería, an earth-based art practice that is passed down between generations, and derives from an extensive body of knowledge about safe and empowering births.

This anthology is both a safeguarding of the caretaking traditions of partería as well as a broader invitation to consider the role of birth work in organizing against war, imperialism, and corporate power. Here, the beauty of the testimonies—and the care with which they were compiled—ultimately come together to upend our ideas of what a medical ethnography can be and what an oral history can do.

INTRODUCTION

During an assembly of the Association of Midwives Rosa Andrade (APRA) of Suchitoto, El Salvador, in September 2021, one of the members, Natividad Escobar de Henriquez, got a call for help from another community midwife. While the midwife had been caring for her daughter who was giving birth at home, a government health promoter had arrived and threatened to call the police if they didn’t take her to the hospital to give birth.

“Put the health worker on the phone,” Natividad said to the other midwife.

“You have to let this woman decide where to give birth, and if she wants to give birth with her mom, who’s a midwife, she’s within her rights to do so,” she informed the government health promoter.

With the blessing of her fellow APRA members, Natividad left the meeting to help the midwife defend against the threats of the health promoter. I had the honor of accompanying her and we were both present for a beautiful birth where the woman giving birth could completely trust in her own body and in the wisdom of nature, supported by her mother and her community.

In this case, the health promoter backed off when faced with the fierce bravery of the midwives. Since the onset of the COVID-19 pandemic, midwives who had not attended births for many years as a result of government intimidation returned to midwifing for women in their rural communities. Just as the armed conflict had revealed three decades earlier, the pandemic underscored the fact that midwives always offer a fundamental human service. With hospitals overwhelmed, turned into spaces of disease and infection once again, the midwives of APRA drew on their thirty years of organizing to continue to work together to provide health services to their communities without institutional support.

This group of women tell histories of violent repression and survival, but more than anything they tell stories of love for life. Through a practice of transcendental solidarity, APRA has managed to give care to thousands of women, adolescents, and babies who have been excluded from the cruel economic system that still dominates El Salvador. The members of APRA have attended births in the middle of the Civil War, without the proper supplies, while fleeing airstrikes and other extremely difficult aggressions. They were there when women giving birth had nowhere to go: in the guerrilla camps, in the refugee camps of Honduras and Nicaragua, and in their own communities when they returned to El Salvador. Under these conditions, many of them began working as midwives in response to the great needs of the people in their communities. Their fight to defend life from violence has continued since those times.

I learned of APRA’s work for the first time in 2018. I was providing education around contraception and lactation to pregnant teenagers and mothers at the health center in La Libertad, El Salvador, while on break from my university in the United States. I saw that the prenatal care that young people were receiving in the health center was incomplete and at times disrespectful. When I asked the nurses about midwives, they told me, “midwives don’t exist anymore” and “that’s a thing of the past.” Aware that midwives are often invisibilized at the global level, I began to investigate what had happened to them in El Salvador. I quickly learned that all of the people over twenty in my father’s town had been born at home with a midwife. A friend who was living in Suchitoto introduced me to two of the midwives in APRA and I immediately felt inspired by their powerful presence. After graduating from university, I returned to El Salvador to work with the association. When I asked the women how I could support their work, they said that they wanted to make a book documenting their history.

I lived with the members of APRA for ten months, joining them on their prenatal visits, at their monthly assemblies, at their social events and soccer games, while I gathered the testimonies for this book. When I think about those women my very cells fill with love. They have treated me like a daughter and living alongside them has transformed the deepest parts of me. I have even continued attending births as a community doula since returning to California.

This collection of testimonies was born of interviews completed in August of 2019 with all of the founding members of APRA and several of the new generation of midwives. By sharing details from their personal histories, the midwives of APRA tell their collective histories. The format of this collection pays homage to their collective model—a structure for protecting their communities and each other as an organized front. Organizing with APRA is an important aspect of each midwife’s identity as one part of a struggle much bigger than herself.

The association has its roots in the armed conflict that took place in El Salvador from 1979 to 1992. The majority of the midwives of APRA began, or rather continued, the work of attending births in the middle of a war fought between a US-backed dictatorship on one side and the Farabundo Martí National Liberation Front (FMLN), a popular guerrilla movement, on the other. The majority of the midwives were involved in the guerrilla political movement and began attending births in the guerrilla camps or among the gente de masa, civilian groups that mobilized alongside the guerrillas.

The Salvadoran Civil War was a continuation of the violence and repression that began with the arrival of the Spanish in El Salvador in 1524: the first chapter in the ongoing colonizing of Indigenous peoples, including the Náhuat-Pipil, the Lenca, the Maya Ch’orti’, the Maya Pocomam, and the Cacaopera. Four centuries later, virtually all of the land and wealth in El Salvador belonged to fourteen families, descendents of the colonizers. The Fourteen Families controlled coffee production, which was the country’s main export. In 1932, the Armed Forces suppressed a revolutionary movement, murdering over thirty-thousand campesinos and workers—the majority Indigenous—who were fighting for a more just political and economic system. The government began killing people for simply appearing Indigenous or speaking their mother tongue. They also assassinated key leaders such as Farabundo Martí, who was one of the founders of the communist party in Central America and later became an icon for the revolutionary party in the 1980s. After the massacre of civilians in 1932, the coffee oligarchy handed control of the country over to a military regime that immediately robbed the campesinos of the right to organize. The country remained under the control of military dictatorships for the following decades. When the war began, at the end of the 1970s, 2 percent of the population owned 60 percent of the country’s cultivable land.

The midwives explain that the popular guerrilla movement mobilized because the people would no longer endure injustice. In 1979, there was a coup d’etat backed by the United States with the objective of avoiding a leftist revolution. The military continued torturing, abducting, and killing any civil and religious leaders who were considered critics of the regime. In 1980, archbishop Óscar Arnulfo Romero was assassinated by the government the day after a mass in which he called upon the military to end the repression. That same year, five left-wing parties joined forces to form the FMLN. In her interview, María Dolores Hernández de Rivera recounts how the guerrillas called it “a fight for the poor.” For many of the midwives of APRA there was no option but to join the guerrillas: they joined because the army and the death squads were persecuting them for being campesinos and for being from certain communities that were politically organized, including Suchitoto. The guerrilla was their only protection.

The midwives were politically formed within the guerrilla movement, which was inspired by Marxism and Liberation Theology. They continue bearing a collective and anti-capitalist spirit. They do not charge women for their services and sustain themselves with solidarity and social organizing. Their fight is still a fight for the poor. All of the founding members of APRA are survivors of this war, which took the lives of approximately eighty-thousand people—the great majority at the hands of the Salvadoran government, which received the equivalent of a million dollars of military assistance a day from the United States. Every single founding midwife lost loved ones during the war—husbands, sons and daughters, sisters and brothers, fathers, mothers, uncles, aunts, cousins. In the midst of this violence, they protected the lives of women giving birth and their babies. They attended births under the most difficult imaginable conditions that the Salvadoran people have lived through.

During the armed conflict, 25 percent of the population of El Salvador was forcibly displaced. Some of the midwives of APRA attended births while fleeing violence, or in refugee camps in Honduras (where twenty-thousand people sought safety) and Nicaragua, where access to health services was extremely limited. The refugee camps were surrounded by soldiers and people were not allowed to leave without permission from the United Nations (UN). On top of that, there were very few doctors to care for thousands of people. The midwives continued to be a fundamental resource for the health of an entire people who had been forced to flee.

At the beginning of the nineties, as the war came to a close with the signing of the Peace Accords, thousands of displaced people returned to repopulate the municipality of Suchitoto in the department of Cuscatlán; there, they built new communities with the scarce resources available. In that time, the only hospital in Suchitoto was inaccessible to the people who lived in rural communities, and midwives were the only aid available for births and other medical emergencies. Public health infrastructure was very precarious. Between 1993 and 1998, 42 percent of births in the country took place outside of a hospital; in some places that had been repopulated by former guerrilla combatants and refugees, such as the Cuscatlán department, closer to 70 percent of births took place at home.

Between 1993 and 1994, forty-five women organized to receive a formal training in midwifery through a program established by two nurse-midwives from the International Medical Relief Fund. In 1994, APRA was born, and ever since, the midwives of Suchitoto have been organized. They continue to meet the first Wednesday of every month to share experiences and make a count of the number of people served by the organization. They also sell pupusas to people in the community to raise funds to buy birth control pills and other materials needed in their communities.

The ancestral role of the midwives is a unique one that includes many kinds of community attention. Being members of the same communities that they serve engenders a deep trust in the midwives by the people; this is not always the case with government health promoters. It’s this trust that allows the midwives to offer diverse kinds of care that transcend a single sphere of health: the midwives of APRA offer talks about sexual and reproductive health; they distribute contraceptive methods in the communities; and they also care for people’s emotional health when someone is sick or injured. Attending births is just one piece of their work.

This model of traditional community midwifery has been transmitted from generation to generation. Many of the members of APRA have learned care practices to aid birth and how to use medicinal plants from their own mothers as well as from elder midwives in their communities, even learning from the same midwives who delivered them a generation before. The wisdom that midwives safeguard has survived centuries of colonialism, a colonialism that continues to devalue Indigenous knowledges above all those practiced by women.

Birth has always been a microcosm of our relationship with nature; it’s not a coincidence that the growing medicalization of childbirth has coincided with the neglect of Mother Nature. Midwifery is an art form that seeks to protect our connection with nature and impart the knowledge that our ancestors have passed down.

Midwives have been subject to extreme repression in the last decade. Around 2011, workers from the Ministry of Health began a campaign of intimidation directed toward midwives in their own communities, telling them they did not have the right to attend births—and that, if something went wrong with a birth, they would get sent to prison. That same year, the Salvadoran Ministry of Health published a policy decreeing that all births must take place in a hospital as part of their “Strategic Birth Plan.” In her testimony, Patricia Hernández shares how the director of the Ministry of Health at the time told the association directly that if it were up to her, “midwives wouldn’t exist on this planet.”

This attempt to eradicate community midwives was a response on the part of the Ministry of Health to the United Nations’ “Millennium Development Goals,” instituted in the year 2000, one of which was to reduce maternal mortality by 2015. This goal was in part measured by a specific target of the number of births attended by “skilled health personnel.” For many countries, El Salvador among them, complying with the Millennium Development Goals became one of the conditions required to receive international aid from countries like the United States. In 2010, the UN published a report about the progress of these goals. Just after this report came out, midwives all over the country, including those in APRA, began to receive threats from Ministry of Health workers.

So what happens when dominant powers define and finance “development” in other countries? In The White Man’s Burden, American economist William Easterly classifies the people in charge of establishing objectives like the Millenium Development Goals as “planners” rather than “searchers.” “Planners” set enormous, even utopian, goals for communities that they are not part of. This top-down hierarchical model means that the so-called solutions to problems like high rates of maternal mortality are not based on the needs and desires of the actual people living in the communities. Moreover, these planners measure their results entirely in numbers, and toss out the importance of people’s real, lived experiences.

Instead of investing resources and training in midwives to support their community work, the type of work that has reduced maternal mortality in other countries, the then Salvadoran government excluded midwives entirely from the formal public health system. The repression of midwives represents a threat to the health of many women and babies who live far from a hospital or who don’t trust health institutions.

According to the Ministry of Health, in 2012 five of six of the most common causes of death for women between the ages of twenty and fifty-nine in El Salvador were related to pregnancy and birth complications; the majority of these deaths were preventable. Midwives live in rural communities, ready for any emergency. It should be added that women put their trust in midwives, and tell them if they have any doubt or if something feels off. Community midwives prevent maternal and neonatal deaths thanks to the early detection of obstetric emergencies.

Birth is not by definition an emergency, and in general does not require any intervention; without a doubt, the Westernized health system treats all births as medical emergencies that need to be controlled. Just as the midwives know how to identify the signs of danger and will accompany women to the hospital when they present with emergencies that cannot be treated at home, they also know to treat birth as a natural process that requires patience and intuition. The fundamental difference between the ways that a midwife and a doctor conceptualize birth sheds light on the distinction between delivering at a hospital and giving birth at home with the support of a midwife.

The ritual of giving birth in a hospital under the complete control of a doctor has become a part of the cultural fabric in the last few decades, one that reproduces colonial relationships and results in physical and emotional wounds for many people. These wounds are the result of obstetric violence, a legal term Venezuela powerfully defined as “the appropriation of women’s bodies and reproductive systems by health officials, which expresses itself in dehumanizing hierarchical treatment, and in the abuse of medicalizing and pathologizing natural processes, leading to a consequent loss of autonomy and the ability to freely make decisions about their bodies and sexuality, ultimately negatively impacting quality of life for women.” Unnecessary or forced C-sections are one of the most easily statistically documented kinds of obstetric violence. UNICEF reports that C-sections represent 32 percent of all births in El Salvador, three times the level recommended by the World Health Organization. When the rate of C-sections exceeds 10 percent, there is no evidence that infant mortality goes down.

Unnecessary C-sections are not the only act of obstetric violence, and are probably not even the most common form. Obstetric violence includes violations of the right to receive information and make decisions, as well as the right to protect intimacy and dignity. Episiotomies, where doctors make an incision in the back wall of the vaginal opening, are violent and unnecessary procedures that historically were common in hospitals in El Salvador. In many cases, this procedure has been done without the consent of the woman giving birth. In 2019, in their study entitled a “National Survey on Sexual Violence Against Women,” the Salvadoran General Directorate of Statistics and the Census found that 71 percent of people who gave birth in the hospital were victims of obstetric violence.

The current first lady of El Salvador, Gabriela de Bukele, has taken an interest in the issue of birth, and in 2021 the Legislative Assembly approved her Nacer con Cariño (Born with Love) law, which promotes “birth with kindness and respect, with kind and sensitive care for newborns.” This law established some important rights for women giving birth, including the right to be accompanied by someone for support during birth and the prevention of health personnel from performing any intervention without receiving the informed consent of the person giving birth. It also included plans to train and certify more health workers focused on perinatal care, but it neglected to consider the role of traditional midwives.

Recognition for the work of midwives seeks not only to bring justice to the women who have dedicated their lives to caring for their communities but also to safeguard birth as an event that can bring us closer to our ancestral roots. The physical body can be a medium for spiritual healing and cultural transformation. Experiences where we become portals of power and transcendental love, such as community births, help us recover what we have lost to colonial history. The suppression of traditional midwives results in a tragic loss for families, for communities, and for the people.

The midwives of APRA fight for a future where the autonomy and intuition of each person giving birth is respected, and where new generations can learn and benefit from this irreplaceable tradition. These women teach us that birth should be a territory of nature and of our own communities, not of the State.

—NOEMÍ DELGADO
San Diego, California
2024

NOEMÍ DELGADO is a doula, body worker, and childbirth educator. Born in San Diego, she began her birthwork journey while living and working with midwives in her family’s homeland of El Salvador, where she received training in traditional birth and postpartum care from members of the Asociación de Parteras Rosa Andrade. In 2019, she was awarded a Public Health Fullbright Fellowship to continue this work. She is cofounder of Cuidando A Las Que Nos Cuidan, a collective generating ongoing support for APRA, and is director of Matronas: The Struggle to Protect Birth in El Salvador (2021), which was an Official Selection at the San Diego Latino Film Festival and the Oakland Short Film Festival and won Best Cinematography at Documentary Short Film Festival. Delgado is dedicated to uplifting ancestral wisdom and challenging the systems that attempt to erase it; Guardianas and Matronas are a part of that effort.