Ngöbe women’s key to childbirth in San Vito Hospital: traditional midwives, spiritual leaders and special diet

When Ngöbe women present with low-risk pregnancies, they are encouraged to give birth following their cultural traditions. This way, they feel as though ‘white medicine’ is not being imposed on them.

San Vito, Coto Brus. It is Wednesday nearly 4pm in San Vito Hospital, Coto Brus, near Panamá´s border. A Ngöbe woman, Marta Marcusi, arrives in A&E. She is 36 and this is her ninth pregnancy.

– ‘Are you here on your own?’ asks Elián Valverde, obstetrics nurse.

– ‘Yes’ she answers.

Prior to her first medical check-up, she chose to wear green garments, very similar in shape to the one used by Ngöbes on their everyday life. Ngöbe women who come to the clinic to give birth have the choice of wearing the conventional hospital robe or these garments, made with the same textiles, but a different type of green.

Valverde spoke to Marcusi to explain that she has the right to call a midwife of her choice to support her during childbirth, or some other specialist in traditional medicine from the Ngöbe people, or a cultural mediator who may help her to translate if she is not fluent in Spanish.

Also, she can choose who stays with her by her side during her admission into hospital. She is reminded that she can give birth in whichever position she finds easier, opening a wider range of options to lying down (the conventional way in public health centres). She can follow the traditional midwives’ recommendations for childbirth: sitting down, squatting or standing.

Next morning, Marta is holding her baby and free of the pain she experienced the day before. She acknowledges how the care received this time was completely different to previous times.

‘They had never cared so much for me or bothered incorporating my beliefs or way of thinking. I am very happy to have my baby with me. In the past, I was once even dumped in the middle of a corridor’ admitted Marta, who had given birth to some of her previous children at home and some others in the medical centre.

By her side, 13-year-old Inés Romero holds her first child. She was accompanied by her mum during childbirth and although she is not a midwife she has basic knowledge and guided her with her voice while the obstetricians were carrying out their work. This support was key for Inés to be peaceful and calm so that childbirth could be smooth.

‘I am feeling really well and so is my baby. I was very scared, but my mum sang and started guiding me. In the end I was calm’ said the teenager.

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Marta’s and Inés’ cases are not an exception, it has become the norm for indigenous women in this area to enjoy this care approach when their pregnancies are low-risk and pose no threats to their health or that of the babies.

At the same time, in the paediatric ward, Adonay González waits with her baby Estuard Benjamín Hemir, barely a month and seven days old. The baby has been admitted due to respiratory problems, but she explains that since they came in to give birth, and now that her baby is receiving treatment she can feel how different elements of her culture are visible in this medical centre.

‘I have two children and when they were born I had to follow the orders of ‘white people’. With the younger one it has been different; dad was allowed to accompany me and sing our [traditional] chants. Being on your own is very sad. Now he was very proud to be there all the time to see the baby being born: hold, clean, cuddle and talk to him. This is also very important for fathers’ said Adonay.

Medical staff admitted to not having taken into consideration the cultural aspects of indigenous women during childbirth.

It was unpleasant to see the language barrier at times. Or even the way we told them to remove their pants when they could barely move. If their husbands were with them it would be very difficult for them [to undress], it’s part of their culture’ says César Díaz, Head Nurse at San Vito Hospital.

Nurse Valverde also added ‘many women who came here with childbirth pain were left waiting in the corridors, and we would only find out about this in the gynaeco-obstetric ward much later. Other members of staff were very strict in imposing their way of working and made these women feel marginalised’.

Childbirth respecting cultural identity

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TRANSLATION: Ngöbe childbirth 1. Information materials written in native Ngöbere is handed to the mothers. 2. Garments provided in the medical centre are similar to the ones used in their indigenous communities. 3. Women are provided with the choice to be accompanied by their husbands or partners and by a midwife, an indigenous traditional doctor or indigenous cultural mediator. 4. Their dietary requirements are respected: 63% demand to not eat pork and 50% ask for food without salt, many others simply request vegetable soup. 5. Women get to choose the position for labour in line with their indigenous culture and customs. 6. They are hydrated respecting their preference: 64% ask for a traditional herbal tea brought in by their companions.

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Mujeres ngöbes llevarán luz a comunidades indígenas

The consultants at San Vito Hospital knew well that the concept of ‘respected childbirth rights’ cannot be regarded in this area of the country as in other places. One out of five women seeking medical care in the hospital are Ngöbe, so it was essential to adapt to them.

This is how the ‘respected childbirth rights’ programme differs from other similar programmes deployed elsewhere in Costa Rica and is therefore named Childbirth Care Programme focused on a Humane approach to the mother and family incorporating cultural specificity.

‘When a woman comes to hospital we have to talk to them first so that they’re not treated in an ugly way. We all feel embarrassed to be checked-up, to have a doctor look inside your vagina, sticking their fingers. These things are unpleasant. Many women say they don’t want to remove the robe while the baby is delivered, because they don’t want to be seen naked. We indigenous peoples don’t do this, we give the baby the time needed to be born’ explained María Bejarano, a traditional midwife with over 20 years’ experience in La Casona, an indigenous community 40 minutes outside San Vito.

Carmen Romero, who’s helped bringing enough babies into this world that she’s lost count, added ‘many of them don’t speak any Spanish, it’s good to have someone translating. It’s ok that this happens in hospital with a doctor, but there needs to be someone who understands our culture and is present. Many girls live far away and don’t even know the city (San Vito)’.

‘When a woman comes to hospital we need to talk to them first so that they’re not treated in an ugly way. We all feel embarrassed to be checked-up, to have a doctor look inside your vagina, sticking their fingers. These things are unpleasant.’

María Bejarano, traditional midwife

‘Once I came to give birth, and as soon as I opened my legs the doctor was sticking his hands in a violet way, he forced me to remove my clothes in a nasty manner. I wasn’t feeling the pain of childbirth, I was feeling pain in my heart’ admits 53-year old Romero.

Many Ngöbe women have their first child aged 13 or 14 and families with more than 5 children are common. ‘We have seen a decrease from six to four children in the last few years’ revealed Alexandra Gamboa, volunteer doctor who works liaising between the indigenous community and San Vito Hospital.

‘We had to stop imposing our way and opening our minds and be accepting of this community’s concepts and views on childbirth, pregnancy and maternity in general. They need to know that they’ll be sage coming to hospital, that here we’ll provide an environment that protects their life and their babies’ lives as well as their cultural background’ stated Valverde.

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Soldados del agua

Up until now, the changes have been effective. Kattia Palacios delivered her last daughter in February and she has already notices positive changes in the care received.

‘It’s not like before, when they’ll leave me alone and I could only have someone visiting. This time they asked me if I had a midwife coming along, but I said I didn’t because she couldn’t come with me to hospital, and they offered to call her and bring her. Or said I could talk to her as many times as I wished. They also asked me if I wanted to listen to my people’s music and even choose how to go into labour. In the end I was laying down because I was tired, but it was my choice’ said Palacios during an interview carried out by La Nación in her home in La Casona.

Men also acknowledge the importance of adapting to their culture. Rufino Villaneda, was interviewed by La Nación when his second daughter Xiomara was born.

‘I cannot talk on behalf of my wife about the childbirth pain, but I was happy to be alongside her and accompany her all the time. I wasn’t able to do this before and I really felt important [laughs]’ said Villaneda.

Another key point raised by the interviewees was to understand that indigenous peoples are not homogenous. They don’t all have the same customs or worldview, neither do they have the same spirituality. In La Casona alone, home to Coto Brus indigenous community, four different religions are practiced: Roman Catholic, Evangelical, Bahai and Mamatata.

This enticed the staff to immerse themselves in the different subcultures and learn how to approach them. For instance, if a patient from the Mamatata religions comes in, staff will know that she will not eat pork or salty foods. To this purpose, consultants developed a specific ‘Mamatata’ diet so that the patients can be well nourished without renouncing their beliefs.

‘We need them to have all the nutritional support to bring a baby into this world. We had noticed that before they didn’t eat all the food. Adapting the hospital menu for them isn’t difficult at all, since there are many protein options aside pork. And it is also perfectly possible to cook without salt. It is a matter of respect’ stated Yuniriz White, head of nutrition at San Vito Hospital.

Many women also need to hydrate drinking herbal teas in accordance to their customs.

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Consultants started working in this new concept of comprehensive care in 2016, and they presented it a few months later to central authorities of the CCSS (the Costa Rican Social Health Institution). The first changes were shown mid-2017, and currently they are still working despite all the successes achieved.

In 2018 alone, $215.720 have been invested in adapting the hospital, not only for the Ngöbe, but for all women who come into labour in San Vito. This investment covers provision for new beds that can be adapted to different positions, so women can deliver their babies in the most comfortable position. They’ve also purchased reclining chairs for companions and new TV screens, cradles and other items.

In terms of indigenous health care, changes can also be seen in the childbirth preparatory courses, where transport is provided to pick up the parents to be in their indigenous communities and take them to hospital, so they can learn about the process and reflect in depth weeks ahead of going into labour.

‘It is not a blank check. Cultural aspects are respected, but we must also understand that this is a hospital and as such, we must ensure that all processes are in place to protect the mothers and their babies. Hygiene and asepsis measures are respected in line with medical procedures. There are some emergency cases where we’ll have to act accordingly’ said Jorge Granados, Director of San Vito Hospital.

‘When God created us women, he did so to give birth, such as hens were made to lay eggs, but we need to give birth in more natural ways; like hens don’t lay eggs laying down’

Carmen Romero, traditional midwife.

Within the programme, in his role as obstetric nurse, Valverde travelled to Ecuador to upgrade his skills in a hospital that provides services for pregnancy, labour and maternity focusing on the cultural specificities of indigenous communities.

‘You learn a lot seeing how other countries adapt their health services to their indigenous populations. However, this project has a specific identity belonging to our indigenous peoples. It has been developed thinking of these families’ declared Valverde.

In this sense, it is necessary to highlight that in order to develop the project, the indigenous midwives visited the hospital, checked the facilities, provided feedback and witnessed various childbirths. Their opinion was essential.

‘It is important to decide how to have your baby. If you’re laying down, you feel as though the baby was up in your chest. It is better to sit down, so the delivery is quick, and you help the baby out. When God created us women, he did so to give birth, such as hens were made to lay eggs, but we need to give birth in more natural ways; like hens don’t lay eggs laying down’ stated Carmen Romero, who was interviewed by La Nación after visiting and learning about San Vito Hospital.

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One single death raised the alarm
Carmen Romero Palacios has been a traditional midwife for over three decades. She has already forgotten how many babies she’s helped into this world within the Ngöbe community of La Casona, in Coto Brus. Photography: John Durán

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This care programme didn’t come out of nowhere. A very specific incident triggered all the alarms in the medical centre. In 2016 a Mamatata woman died while in labour in her community. She was never taken to hospital despite all the complications that she presented with.

Civil servants from CCSS and the Ministry of Health travelled to the Mamatata village to find out why they hadn’t sought medical assistance. They found that Mamatata people were delivering their babies in places that didn’t comply with minimum aseptic measures and that this could lead women and their babies to suffer complications and infections, especially those that presented with high-risk pregnancies.

The response was one they didn’t expect: ‘you don’t respect our culture and you always impose your way of doing things’ the Mamatata said.

It was then that they started looking at ways to make the community feel closer and trusting of the health services provided.

Alexandra Gamboa, a doctor who carries out ad honorem work in San Vito Hospital, had existing links with the Mamatata and became interested in the project. She looked at different communication root in order to foster understanding and becoming the link needed by the community in order for their voice to be heard.

‘The community wanted to be heard, to be considered and in exchange doctors want childbirths to happen safely. It is about reaching that point where women feel their culture is respected as well as their way of being and thinking, but also that them and their babies are safe. Some find it harder than others to go to hospital, because they feel that us ‘white’ people want to harm them and make them ill. We just needed to listen, for them coming into the world has important implications. For instance, they don’t name the baby until the fourth day of being alive, once they see how the baby behaves’ highlighted Gamboa.

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This talk was given in one of the rooms allocated for Mamatata women to give birth. The leads of the session were Dr Alexandra Gamboa and obstetric nurse Elián Valverde. Pictured in the centre taking notes, Marcelino Bejarano, spiritual leader of the Mamatata community. Photography: John Durán

This is how they started to give frequent talks to Mamatata midwives and explain the emergency signs to look out for and that require specific care in hospital.

‘We don’t want to change you. Just understand, respect and adapt to the extent where it’s possible to prevent mother and child deaths. We respect and admire your culture, we want to learn from you and you from us’. said Valverde during a talk in a Mamatata community attended by La Nación. In this moment, mid-July, there are nine pregnant women from the Mamatata community.

Marcelino Bejarano, spiritual leader of the Mamatata community is still cautious. However, he highlighted how useful the hospital is in cases of emergency. He even acknowledged that thanks to the hospital care another woman’s life was saved during childbirth-related complications in the Mamatata community.

‘This is not just a religious organisation, it is about medicine through natural remedies. Midwives control that natural medicines are taken. It is not only about diet, but also natural medicine. Here we have knowledge that you lack in certain areas. There are spiritual illnesses that have other ways of healing. People also die in hospitals in different ways. There can also be complications in hospitals. But we have agreed that if there are complications, we will seek hospital care. We respect the agreement, but we ask the same of you’ stressed Bejarano.

Little by little, this community has seen how this health institution is opening up to the midwives’ support and the traditional medical approaches, as long as doctors deem these to not interfere with life-depending drugs, and there’s greater collaboration. Both the indigenous peoples and the medical staff acknowledge the importance of having a person working as a link between the Ngöbe and San Vito Hospital.

‘We must keep working, for instance, we need to allocate a position for Dr Gamboa, whose work is essential for this programme. We are much closer to achieving this. In the last year only 25 babies were born outside hospital, many of them live in remote areas and couldn’t leave, but most of them returned to the medical centre to be checked, this is paramount’, highlighted Granados.

In the meanwhile, the hospital carries on with the work, since many things need to be done alongside the new improvements.

‘When a baby is being delivered is like receiving a completely new seed, all the bad things go away and we thank God and Mother Earth. If white medicine can understand it this way, then we’re on the right track. Everything must follow God’s and Mother Earth’s will’ stated Romero.

This feature piece was originally published by La Nacion, Costa Rica


Feature image credit: 13-year-old Inés Romero, had her first child at the end of July in San Vito Hospital. She was accompanied by her mum, who drew on the experience of Ngöbe midwives to support childbirth. John Durán

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