Marcela Chávez was already an advanced biology student when she decided to drop out and start over – this time to become a midwife with a degree in obstetrics and childcare. She finished her degree more than three decades ago when she was 24 years old, and went to work in the province of Chiloé, more than 900 kilometers from her home in Bio Bio, Chile.
Montevideo, May 5, 2021 (CLAP/PAHO)
Marcela is one of the 12,000 midwives in Chile and one of an estimated 65,000 midwives in Latin America, where 10.5 million births occur each year. Midwives play key roles in maternal and perinatal health care and as specialists in normal delivery, newborn care, and sexual and reproductive health.
Chiloé is an island in the south of Chile with less than 170,000 widely dispersed inhabitants and an adverse climate that makes it difficult to access some localities.
When Marcela arrived in Chiloé, she was assigned to Queilén, a town and commune.
At that time, it was very remote and there were areas that were very difficult to access. It took us three hours to arrive by boat when there was a storm. We were even in a shipwreck! The important thing was to reach out to these women and support them. At that time, those places were very hidden and isolated from health care.”
Since 1994, she has been working at the Ancud hospital, located in the city of Ancud. As a midwife - in Chile they are called matronas – she does rotating shifts and works in the emergency department, labor and delivery, neonatology, gynecology and on high-risk cases.
When she started working at the hospital, it attended 1,000 births a year, which has since been reduced to 400 births in line with demographic changes worldwide. She has also noticed cultural changes – a greater concern for making certain the woman, not the doctor or the institution, is the important figure at the moment of delivery.
Here, at the hospital, we have a maternity ward with personalized care. There is a special room and we emphasize the father's involvement and attachment (with the mother giving birth). There is a cultural approach, and all the colleagues are trained to provide this care.”
In addition to compassion, Marcela says training is essential for a midwife. “We need the scientific part – the knowledge that allows us to help the woman. Maternal and perinatal mortality rates would not have been lowered without this knowledge. I have to know what I am doing, and when and how to intervene” if necessary, she says.
It is estimated that midwives trained in maternal and newborn health interventions and family planning will be able to reverse 83% of maternal, neonatal, and fetal deaths by 2025.
The State of the World’s Midwifery 2014 – a publication of the UN Population Fund (UNFPA), the International Confederation of Midwives (ICM), and the World Health Organization (WHO) – reports that investment in midwife training “could generate a return 16 times greater than the investment made, in terms of lives saved and savings in caesarean sections avoided, and is an optimal option in primary health care.”
Dr. Bremen de Mucio, regional advisor on maternal health at the Pan American Health Organization (PAHO), said “At the Latin American Center for Perinatology (CLAP) of PAHO we understood that it was necessary to further professionalize the training of professional midwives. For decades, many midwives were ‘trained’ using outdated educational models. But in the last 15 years, we have been supporting the training of midwifery teachers, based on competency-based education models with very good results.”
The State of the World’s Midwifery emphasizes the importance of the availability of midwives and an accessible care system with "an adequate geographic extension of health facilities and agents, supported by good transportation, information and communication networks."
For Dr. De Mucio, "The professional midwife is an invaluable resource within health systems. Unfortunately, some health systems continue to ignore their relevance and do not consider that all women, even those in the most isolated places, have the right to quality care provided by midwives with the necessary skills.”
He points out that in Latin America and the Caribbean, “there are vast geographical areas where the only qualified resource for childbirth and newborn care is the professional midwife. And although the communities give them prestige and recognize their role, the States (countries) do not always recognize their indispensability, and their salaries and working conditions are not consistent with the vital role they play.”
Midwife Daniela Ramírez works at the first entry point to the health care system in the Family Health Center (CESFAM) Quemchi, a town and commune in Chiloé: “It (Family Health Center) is the first approach to women – it aims to prevent diseases and health promotion. The midwife can work in various areas of women’s life cycle," she explains.
Daniela is in charge of the insular sector, which has four islands that she visits twice a month with a multidisciplinary team. It takes her more than an hour to travel by boat from CESFAM to the nearest island and nearly two hours to travel to the farthest island. Daniela has 400 women in her registry and follows up on each one of them.
"I handle checkups for pregnant women. When they reach 36 weeks, we refer them to Chiloé so that they are not at risk. I do dyad checkups (which are performed on the mother and her baby between seven and 10 days after birth).”
When necessary, she refers patients to the Ancud hospital, which is the northern gateway to the island where Marcela works.
For Daniela, empathy in a midwife is indispensable, along with the ability to work as a team. "If a person wants to be a midwife, it is because they like working with people. We must see the woman as a whole, not only worry about the uterus, breasts or genitals, but also the family, environmental conditions and mental health. And we must treat them with respect and provide them with as much information as possible so that they can make informed decisions," she says.
Amid the COVID-19 pandemic, Daniela’s work has only gotten more complex. She has continued with her usual tasks and added testing and case-tracking activities for the new coronavirus. She has ensured the continuation of the care she previously provided, though the consultation time has been extended due to the need to comply with disinfection protocols.
On the other hand, Marcela Chávez, the midwife at the Ancud hospital, says that the pandemic, with its requirements for isolation and physical distancing, has complicated the involvement and presence of the father at delivery.
But “what was an achievement," she says, "was that the first delivery of a COVID-19-positive pregnant woman was followed by exclusive breastfeeding and attachment. It was done with the isolation that was required, but it was still very good.”
In order to support training in the area of maternal health, the Latin American Center for Perinatology (CLAP) of the Pan American Health Organization (PAHO) and the University of Chile offer the Competency-Based Education course through their Virtual Campus for Public Health.
The self-learning course, which has an estimated duration of 18 hours, is aimed at midwifery, nursing or medical teachers. It is based on the competency-based education (CBE) model, an approach that has become widespread in midwifery schools around the world and aims at acquiring competences in a practical way through the application of the contents.
The modules address topics such as the fundamentals of CBE, its instruments and the objective structured clinical examination, and pose complex and contextualized problems for participants to demonstrate that they understand and can analyze the phenomenon.
