Where no one else goes | Translation
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Translated by MC Editorial
[Daniel Alarcón]: This is Radio Ambulante, from NPR. I’m Daniel Alarcón.
Today we begin in southwest Guatemala, in the department of Totonicapán. For centuries, this has been the home of the Quiché people, one of the main ethnic groups of what in pre-Columbian times was the Mayan Empire.
Currently, the Quiché Mayans are the most numerous indigenous group in Guatemala, just over a million and a half people. And most of them live in Totonicapán, a land that does not forget its history. A land where generations of women and men have kept their ancestral practices alive.
At almost 2,500 meters above sea level, amid hills covered with lush trees, there’s a town called Chotacaj. From the air, the houses seem to be located on a board of brown and green squares, depending on what crop is being grown—corn, beans, oats, wheat . . . It’s a cold place, windy and misty, where the drizzle that falls is known by locals as “the health of the people.”
In one of those houses, made of adobe and tile, Graciela Velásquez was born in 1971. And from that moment on, her future, in a certain sense, had already been mapped out.
[Graciela Velásquez]: When I was born, my grandmother brought me into the world and said that I was, ah, the one who would inherit her talent. And she said, “The person who came to take my place has been born. The one who will carry on my work, my talent, has been born, the one who will go forward.”
[Daniel]: María Soledad Rosales, Graciela’s paternal grandmother, was an iyom, which in Quiché means “one who receives new life.” It’s considered a sacred occupation in her culture, and is usually carried out by women.
[Graciela]: It is the supporting, the wisdom, the gift of delivering babies.
[Daniel]: Women have guided births, in all civilizations and cultures, for thousands of years. Grandmothers, mothers, and aunts have taught their daughters, granddaughters, and nieces how to deliver babies. But, according to the Mayan cosmovision, not everyone can be an iyom. It’s not something that is chosen. Graciela sums it up this way:
[Graciela]: We are born to it; we are not made to it.
[Daniel]: Many Mayan women believe this. They are born with the gift of being iyoms, or in English, midwives . . . and fulfilling this role is their destiny. They are heirs of a knowledge that has been transmitted for many centuries, and their life is devoted to caring for the health of their communities.
[Graciela]: We heal babies, we work a lot with plants, healing plants. We are therapists and healers, psychologists, we are traumatologists, gynecologists too, you see.
[Daniel]: It’s no exaggeration to say that without them, the Mayan people might have disappeared. In a country where the State fails to provide public health care to more than half the population—which results in high rates of maternal death—midwives have attended up to 70% of all births.
Graciela’s grandmother was in charge of guiding her in that work from the time she was 6 years old.
[Graciela]: I hung around my grandmother. I brought her the . . . her little things.
[Daniel]: Her basket, scissors, towels, incense, plants . . . everything you need to attend the birth process in women’s homes. In those comings and goings, Graciela watched everything her grandmother did. And little by little, she learned.
[Graciela]: I was very happy because I thought, “I’m going to be a doctor.” And I used to tell everyone that I was a doctor.
[Daniel]: But, as the years passed, she would realize that not everyone in her country saw her that way. That gift that seemed so important in her community was not accepted by the Guatemalan State health system. And then Graciela, along with the other iyom, would have a double confrontation: not only a struggle for the health of the women in their community, but a struggle to earn the respect of a system that fails to value their knowledge and traditions.
Lisette Arévalo and Victoria Estrada researched this story. They’ll tell us more after a short break.
We’ll be back.
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We’re back with Radio Ambulante. Lisette continues the story.
[Lisette Arévalo]: Graciela lived in Chotacaj with her parents and her three siblings. Her father was a carpenter and her mother made wooden boxes and did housework. But Graciela also spent many afternoons with her grandparents, who lived in another community an hour’s walk away. The road was surrounded by forests.
[Graciela]: I went there every afternoon. I did not care how far it was . . . When I got there my grandfather would be performing the ceremonies. I hung around with him, I . . . I would get his supplies.
[Lisette]: Incense, candles, plants . . . Her paternal grandfather was a healer, another of the gifts that the Quiché consider a person to bring with them at birth.
Mayan medicine also includes other specialties. For example, there are the callers, who provide spiritual help to patients whose spirit has been lost after going through a great scare. Or the timekeepers, who meditate on the meaning of people’s lives.
Ever since Graciela can remember, she accompanied her grandfather taking care of the patients who came to his house.
[Graciela]: He said to me, “This—you will heal using this. With the ocote, with the incense, with whatever elements we have. That’s what you will use to heal. I am not teaching you other practices that aren’t your own,” he would say.
[Lisette]: Oils, ointments, and teas were made from plants. And each had a different use. In the case of arthritis patients, for example, they were given nettle tea, steam baths, and massages with oils.
They also treated ailments such as the evil eye or fright, which the Mayan healers attributed to bad energies. In Mayan medicine, many diseases are directly related to the spiritual or the emotional.
Graciela spent the rest of her time helping her mother at home and going to school. But when she turned 9, her routine suddenly changed.
[Graciela]: I asked my father to help me with my studies and my father didn’t do that. He let me go only as far as the fourth grade, because he said that “women were made to get married.”
[Lisette]: It was his word, period. Besides, it was common practice in their community: girls did not go to school or they went only for the first few years.
So, Graciela had no choice but to stay at home, helping her mother with the housework. She also began to spend more and more time with her grandmother, who was an iyom, accompanying her during the deliveries.
[Graciela]: So, ah, she told me (speaking Quiché).
[Lisette]: Her grandmother spoke to her in Quiché, her mother tongue.
[Graciela]: In other words, “You are coming with me, we are going to see the patient, the girl is going to get better.”
[Lisette]: Graciela liked to go. But she had to do it secretly because her mother did not agree with the gift that had been assigned to her at birth.
[Graciela]: My mother did not want that, because she said, “You are going to suffer, you are going to be hungry, you are going to be cold along with those people. Your sleep . . .” she told me.
[Lisette]: Being a midwife is a job that requires a great deal of sacrifice. They have to be available at all times and make long trips to remote places. They receive almost no financial compensation for their services, beyond a symbolic gift—corn, beans, sugar. And if they receive money, it’s usually not more than 100 quetzals—about $13—for months of care, from the beginning of pregnancy to delivery and afterwards.
[Graciela]: And my mother said to me, “A baby could die on you, then what are you going to do?” And it was a huge responsibility.
[Lisette]: But being an iyom is also something that cannot be so easily rejected. According to the Mayan cosmovision, those who deny the path that has been marked since their birth, face great suffering. From illnesses to the death of loved ones. And the only possible cure is to accept your mission.
Despite her mother’s opposition, Graciela did like the idea of having been born an iyom. She enjoyed accompanying her grandmother and learning from her.
[Graciela]: When I got back, they would scold me, but I did not care. What I wanted was to accompany her, and I felt happy.
[Lisette]: The care that her grandmother provided, and that Graciela would one day provide, was not limited to assisting in the delivery. Mayan women look to the iyom to support them throughout the pregnancy process, because they trust them, they share their culture and speak the same language.
The support begins with prenatal care.
[Graciela]: Making sure they don’t have back pains, they don’t experience vomiting, they don’t get headaches.
[Lisette]: Her grandmother visited them once a month and gave them massages. She also gave them advice on how to take care of their pregnancy and what they should eat.
When they reached the seventh or eighth month, she started visiting them every two weeks or every week. And more, when the labor pains began, making sure the baby was in the correct position.
[Graciela]: And we, well, we give them their hot teas, their . . . their plants.
[Lisette]: Such as lily, to help with childbirth, or fig leaf that, when prepared as a hot tea, helps reduce pain. Or also chamomile and cinnamon that, combined in an infusion, help prevent bleeding.
[Graciela]: The other thing is to administer the baths . . . there is the temascal and there are the plant baths. That is also inherited, it is part of the Mayan wisdom.
[Lisette]: The Mayans have used the temascal bath as a medical resource for centuries. In a mud hut with a campfire in the middle, they heat up stones on which plant infusions are poured, creating steam baths. Midwives use it for body cleansing or relaxation and healing rituals during pregnancy, before and after delivery. And they often compare the warm darkness of the hut to a mother’s womb.
When delivery approached, Graciela’s grandmother could spend several full nights with her patients, waiting for the birth to happen.
And she took this opportunity to prepare her granddaughter to exercise her gift.
[Graciela]: And she says to me, “Do not force it . . . do not make them push ahead of time. Before you figure things out,” says my grandmother.
[Lisette]: They also used to perform a ritual.
[Graciela]: (Speaking in Quiché), she would say, “You leave all your candles and ask for that wisdom. And the grandparents tell you, they let you know whether this birth can take place at home and whether this birth is going to have risks.”
[Lisette]: Graciela says “the grandparents” or “the grandmothers” to refer to her ancestors who were also healers or midwives. According to Mayan belief, they are the ones who accompany and guide their work, through dreams.
If they perceived that a birth could be risky, her grandmother would take the patient to a health center or hospital. Although this wasn’t always possible because many of the women lived in remote communities.
If they didn’t think it was risky, the delivery took place in the home. Her grandmother put on her sut, a scarf that the iyoms tie on their head as a symbol of respect for childbirth. She also lit incense to purify the air and to carry her prayers to Ajaw, the creator god. Then she invited close relatives to accompany them and helped the woman find a comfortable position.
[Graciela]: Always kneeling, squatting or also sitting. And the other thing too, right? Like tying yourself from a sheet on the roof, and there we were, waiting for the baby.
[Lisette]: In other words, the woman would hold on to a sheet that was suspended from the roof of the house, in order to give birth in an upright position. It was the decision of each patient as to which position they wanted—something they were not allowed to do in hospitals. Once the baby was born, her grandmother cut its umbilical cord, gave it steam baths, or cleaned it with cloths soaked in hot water, and handed it to the mother.
[Graciela]: When a baby is born, you tell the father, you know?, the mother . . . You give them candles, incense, fire and you give thanks. And I say, “Here is the baby. I offer it up to the heart of heaven, the heart of Mother Earth.”
[Lisette]: Lastly, her grandmother took care of the placenta, something that for the Mayans is sacred because it generates life. Graciela helped do a ritual to burn it or bury it under a tree. And after the delivery, they visited their patients for postnatal checkups.
Graciela watched everything her grandmother did and imagined herself following her path. Walking over hills and through forests, helping bring life to the earth. It was something that filled her with joy.
[Graciela]: Because it is also a life that comes to see the light, right? To see Mother Earth, to cry, to laugh, to sing, to talk, to also feel . . . well, what we are feeling.
[Lisette]: During her years of learning, Graciela limited herself to watching and helping. But at age 13 she had a dream in which her ancestors appeared.
[Graciela]: It was the grandmothers Ixquic, Ixmucané, (unintelligible), Ixchel that were with me, because there were four of them and they were there, the incense was there . . . They taught me the pimpinela, they also taught me the fire.
[Lisette]: They taught her, says Graciela, how to attend her first birth.
[Graciela]: And . . . they told me, “This is how you are going to do it, this way, this way,” but in Quiché, “[Quiché]” they said, “All right?” That dream did not scare me, but it was like a very vivid experience.
[Lisette]: Many midwives say that their first instructions on how to handle deliveries came to them through dreams. Graciela is convinced that it was not by chance she had it at that very moment.
She didn’t know it when she woke up. But she would understand a few hours later.
It was early morning and Graciela was in bed, when a woman she lived with came to her room looking for her. She was in the final weeks of pregnancy.
[Graciela]: She told me, “Look, I am in pain and I cannot bear it.”
[Lisette]: An aunt of Graciela, who was at home, sent for the midwife who had been accompanying her for months. But while they waited for her to arrive, the woman’s water broke. Graciela got nervous—she would have to take charge.
[Graciela]: I said, “Will I be able to, or will I not be be able?” But since I was rebellious, you know? A warrior and a guardian. So, I said, I have to be able. If the grandmothers have given it to me, if they could, why can’t I?
[Lisette]: She brought out hot water and grabbed some towels she had at hand. She helped her onto the bed, helped her get down on her knees, and the woman began to push.
[Graciela]: And she says to me, “No more. I am about to do it, I am about to do number two.” “I say, “No, it’s not number two. It’s the baby’s head.”
[Lisette]: Since Graciela did not have a scalpel or delivery tools, she took some scissors she had for sewing, ran them through hot water, and cut the umbilical cord. She cleaned the baby, wrapped it, and very carefully handed it to the mother.
[Graciela]: I can’t remember if I was shaking or not . . . But I handled that delivery without a single complication.
[Lisette]: When her grandmother got to the house, she realized Graciela had not only handled her first birth, but had also given the mother a bath with plant infusions and had girdled her so that the uterus would stay in place.
Then she went over to where she was, and said:
[Graciela]: “Now you can do it. Now I can go in peace, I am going to my rest because you are going to stay to continue in my path.”
[Lisette]: But her mother still disagreed. Later, when Graciela came home, she was furious when she found out what had happened.
[Graciela]: “How can that be, you are just a little brat, this and that,” and my mother hit me. It was very painful. Instead of saying, congratulations, daughter . . . no, she hit me.
[Lisette]: She believed she was not old enough for such things, and it would be several years before she would start to support her. But Graciela didn’t wait for her authorization: she started attending deliveries in the community where they lived.
Four years later, when her grandmother died, she was already recognized as an iyom. She was only 17 years old.
Graciela had to start delivering babies in increasingly distant communities, walking through the mountains where no doctors ever go. Her grandmother’s patients were now hers.
[Graciela]: She entrusted me with looking after her patients and looking after her patients’ children. Her patients’ grandchildren, the patients’ great-great-grandchildren.
[Lisette]: Let’s remember that midwives in Guatemala have performed up to 70% of all deliveries throughout the country. And in many rural areas, there is no alternative. In 2015, the United States Agency for International Development conducted an in-depth study of the Guatemalan health system. In it they pointed out that the rural areas of the country have only three medical workers for every 10,000 inhabitants. And that almost three million Guatemalans live at least five kilometers from the nearest health center. In addition, many of them live in mountainous areas.
These are the type of territories where only midwives like Graciela go.
[Lucrecia Hernández Mack]: That primary care network is enough to serve . . . to cover around 6.5 million people, which is the population that Guatemala had in the mid-70’s.
[Lisette]: That was Lucrecia Hernández Mack, a Guatemalan doctor and congresswoman, who worked in public health for 20 years before going into politics. We spoke with her to better understand what is happening with the health coverage and the indigenous communities in her country. And she clarified something for us: When she was Minister of Health, between 2016 and 2017, she came up against a backlog of almost half a century.
[Lucrecia]: It’s a historical lag, right? With many deficiencies, so it cannot, for example, take care of things beyond diarrhea or pneumonia. But it can’t take care of all the problems such as diabetes, hypertension, cancer, heart attacks, strokes, violence, accidents, or let’s say, injuries, addictions or mental health problems.
[Lisette]: And maternal issues are no exception. Historically, Guatemala has had one of the highest maternal death rates in Latin America. In 2017, according to the United Nations, there were 95 maternal deaths per every 100,000 live births. The average for the region was 74. These are deaths of women during labor or postpartum, which occur due to hemorrhages, infections or high blood pressure, among other causes. Of those deaths, in the first quarter of 2019, 6 out of 10 were Guatemalan indigenous women.
And in hospitals, midwives are usually the ones targeted.
[Lucrecia]: Maternal mortality is a structural problem, you know? It has more to do with the economic problems of, let’s say, the absence of the State, of infrastructure, of health coverage, than the fault of the grandmother midwives—who at the end of the day, are the ones that have managed to help where there is no State presence. Where there are no health services.
[Lisette]: There are an estimated 60,000 midwives or more in Guatemala, and Lucrecia believes, in fact, that the only real possibility of reducing maternal deaths is by coordinating and supporting their work. But it is not so easy. The tension between the state health system and the practices of Mayan medicine has been going on for many years, and is rooted in other deep-seated problems in Guatemalan society.
[Lucrecia]: In general, here in Guatemala there is racism, right? So, let’s say that therapists, grandmother midwives . . . or any other alternative medical or health system, has always been viewed in a negative light. So, they just come and label them as a matter of backwardness or witchcraft, or superstition.
[Lisette]: That, added to the idea, in some medical circles, that they do not provide care in clean conditions, has placed them at the center of the conflict.
[Lucrecia]: It´s a question of discrimination, but also of blame, right? Of blaming them for maternal deaths.
[Lisette]: Over the years, Graciela began to understand this, as she traveled miles to care for the daughters and granddaughters of her grandmother’s patients. She still liked what she did, even though it involved a great sacrifice. At 22, she married a young man from her community, chosen by her parents without consulting her. She only asked him if he was going to respect her work, and he said yes. By 1996 they had the first of three children, and Graciela had to manage being a mother while helping others to be mothers as well.
It was during those years that the situation between the State and the midwives started to become increasingly contentious. In the previous decades, the Ministry of Health had launched several programs with the idea of training midwives, but they used to run into the same cultural barriers. These were courses in which there was no space for Mayan medicine.
In practice, the women had to attend training sessions and pass an exam to receive an official card. But many midwives felt bad about how they were treated during training, and chose to continue doing their work without a card. Graciela was among them.
[Graciela]: They would not listen to us and I didn’t like being ordered around, you know?
[Lisette]: The government’s proposal was part of something larger. In 2001, the Ministry of Health created policies to meet the UN Millennium Goals to reduce maternal mortality around the world. One of the most important was that more deliveries should take place within hospitals, with medical personnel. This meant, in practice, that midwives were forbidden from attending first-time or twin births, as those were considered risky.
[Graciela]: Because there they prohibited many things. And at the health center we are penalized if we diagnose by touch, if we attend the delivery, or if there are any risks involved, if her hands are swollen, if her head hurts, if her feet hurt. So the health center was the hardest thing for me.
[Lisette]: At the same time, health personnel at some centers threatened midwives, saying that if they practiced without the card, they could be fined—although for many, it was almost impossible to get to the health centers where the training took place. They lived in remote areas hours or days away, and many did not have the resources to move around or to pay the roughly $13 to $20 that the entire process cost. Graciela also learned of some midwives who were detained for attending deliveries without prior control at a health center, and others who complained of receiving jail threats for their practices.
In 2001, while the situation was becoming increasingly difficult for midwives, Graciela decided to go back to the Totonicapán health center. She wanted to get the card that would allow her to register the births she attended, and to accompany her patients in case they needed to go to the hospital. But soon, the problems began.
[Graciela]: They had to test me to see if I really was a midwife. So, I had to do nine deliveries . . . I mean, I had to take photos and bring them to the health center to prove I was the one who performed the delivery.
[Lisette]: At first, Graciela resisted, because it meant violating her patients’ privacy. But without that, there was no license. So, she complied.
However, she also felt uncomfortable during training. A lot of it was taught by medical or nursing students, who did not appear to have any experience attending deliveries. The information they were given seemed basic, and no pedagogical materials or clinical practices were provided. They only insisted that deliveries should take place in sanitary conditions and that in the event of any risk, they should send their patients to a hospital.
Graciela felt that they spoke to them as if they knew nothing about what they had been doing for years.
[Graciela]: They would ask us, “How do you do such-and-such? How do you place the patient? What do you give the patient?”
[Lisette]: Questions, furthermore, that were asked in Spanish, a language that most midwives hardly understood. In Totonicapán, more than 90% of the population is Quiché and, with the occasional exception, the nurses at the center did not speak their language.
[Graciela]: There was a lot of racism because we only spoke Quiché. So the nurses would say, “Oh, we don’t understand you.”
[Lisette]: Graciela says that some trainers even mocked them.
[Graciela]: “They are fishwives, they don’t know anything.”
[Lisette]: Although various international conventions and government resolutions said they should respect the cultural practices of Mayan midwives and patients, this did not always happen. Graciela understood it through something very specific: She was not allowed to enter the health center wearing her traditional clothes.
[Graciela]: I felt very discriminated because my clothes were taken from me, when clothing is not a sin, it does not have bacteria or anything.
[Lisette]: It was the Mayan clothing that she had been wearing for years to attend births, the same as those her ancestors had worn: the sut or headscarf, a sash, a skirt and a colorful blouse.
Several midwives reported that when they filed complaints about this treatment to the head of the health center, their card was taken away. In addition, Graciela says this also happened when they could not attend meetings.
[Graciela]: Because if we miss one, two or three of the meetings, the training sessions, the nurse comes to the health center and they take away our card. They take it away from us.
[Lisette]: And without a card, it was as if they did not exist for the Ministry of Health. This amounted to taking away the right to accompany their patients during their delivery at the centers, or to register the children they delivered.
With the new measures promoted to increase hospital deliveries, midwives who held a card began to accompany their patients to health centers much more often. But this generated more conflicts.
[Graciela]: Because the discrimination is not only against us midwives, but also against our patients . . . It is violence because you come in with your patient, and right there in the hallway they say, “Ah, no, we don’t want a midwife here, show them the door.”
[Lisette]: Graciela’s experience was not an isolated case. The Association of Community Health Services of Guatemala has collected the testimony of more than 70 midwives, who report similar things: nurses or doctors denying them entry to the hospital; derogatory statements, such as saying they “get in the way” or “they get things dirty.” Many reported they were not allowed to explain in what state their patients arrived, even when there was no bilingual staff at the health center, and only they could have served as interpreters.
Graciela even heard a nurse yelling:
[Graciela]: “You have already been touched by a midwife. You stay there.” And they left the patient screaming.
[Lisette]: These scenes shocked Graciela.
[Graciela]: In other words, delivery care in the hospital, well, there is a lot of violence. It is obstetric violence, I call it. They do not listen to them, they discriminate against them, they hit them, they abuse them.
[Lisette]: Obstetric violence occurs when health professionals cause physical or psychological harm to their patients before, during, or after childbirth. Graciela says that, in those years, several of her patients were stripped naked and left unattended for hours. And other times, deliveries were made to occur early or invasive procedures were done—such as cuts in the perineum to avoid tears—without explaining the risks involved. She also claims that some women complained of having unnecessary cesarean sections or enduring rough vaginal examinations.
[Graciela]: From the nurse to the medical resident, they are all doing . . . well, watching the dilations. But there are those who do not have the patience to do a tactile examination. So women leave the hospital with serious lacerations.
[Lisette]: A vaginal examination is used to check for dilation during labor, but if done carelessly, it can cause lacerations or bleeding. According to a 2016 investigation by the Guatemalan newspaper Plaza Pública, these practices still exist in many hospitals in the country, as well as pressing the abdomen to induce labor, which can cause anything from uterine injuries to a complete rupture of the uterus. In fact, the investigation found that 15 women died from this cause in the country in 2015 alone, according to data from the Ministry of Health.
Graciela heard how those stories of abuse were repeated by the patients she had come to know on her walks through the mountains, from community to community.
[Graciela]: I felt very . . . very sad, you know? And I just told the patients that they, too, had to raise their voices. Do not allow yourself to be mistreated, that is, do not allow yourself to be humiliated at the hospital.
[Lisette]: But nothing changed. Cases of violence kept reaching her ears.
[Graciela]: Because we had nothing to hold on to, to protect the value of the work we were doing. But I did get mad, you know? Very Mad. With real anger. But at the same time, I saw the weakness . . . of how to overcome it.
[Daniel Alarcón]: In other words, things had to change for them and for the women they attended. And it would be the midwives themselves who would push for that change.
We’ll be back after a break.
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[Daniel Alarcón]: We’re back with Radio Ambulante. I’m Daniel Alarcón.
Before the break, we heard how the Mayan midwives, who for decades have taken care of most births in Guatemala, began to be mistreated, together with their indigenous patients.
But they weren’t going to sit still. In 2008, midwife Graciela Velásquez began organizing dozens of midwives from Totonicapán, the department where she lived, to denounce what was happening.
Victoria Estrada picks up the story.
[Victoria Estrada]: That year, Graciela began to have increasingly frequent conversations with the other midwives who were receiving training at the Totonicapán health center. Since they had nowhere to meet, they always got together under a tree outside the center. They spent hours talking about the treatment at the hospital, their working conditions, and what they could do to improve them.
It wasn’t long before they realized that they had to begin by organizing. So they created the Kawoq Association of Grandmother Midwives. The “Kawoq” is the spiritual symbol of midwives, representing the ability to heal, fertility and care of the family.
[Graciela]: The Kawoq association was what brought us all together. It is specifically for midwives. Where we are altogether, one thousand three hundred and forty-six, I think.
[Victoria]: That’s today, but at first there were no more than 50. Although by then, seeing so many women together for the first time was exciting for Graciela.
[Graciela]: I felt very happy because I realized that, well, perhaps the time had come to . . . to complain, to denounce.
[Victoria]: First, they filed several complaints about the mistreatment they received, with the directors of the center, the nurses, and the doctors. Graciela says they talked to them about 25 times. Above all, they claimed they were being denied their card, even though they completed the training. But these attempts at dialogue went nowhere.
[Graciela]: They did not want there to be any more midwives. That was it, they just do not want it. “Why more midwives? There are many midwives and they don’t know their job.” That’s what they used to say.
[Victoria]: But once organized, their claims were harder to ignore.
[Graciela]: I told them, “Give me my card and I will show you what an iyom´s job really is about.”
[Victoria]: Graciela says that, at that moment, she felt the nurses and doctors began to listen to them more. And in 2011, after much insistence, they began to give the card to all the midwives who completed the training. Including Graciela. It was something crucial, especially after a new maternity law, approved the previous year, had formalized the requirement that they have the card to be able to attend deliveries.
Despite this, Graciela says that when they were given the cards again, one of the nurses told them:
[Graciela]: “You are the last class of midwives. There will be no more.”
[Victoria]: The law also indicated that the Ministry should formulate, together with the midwives, a new policy to include them in health services. It seemed like a step forward, but it would be four years before anything began to be created.
It was not until mid-2014 that the Ministry convened 33 round table discussions at the national level, for midwives to give their opinion on what should be included in a new policy. Graciela and Kawoq were part of those discussions.
[Graciela]: We joined the struggle of the dialogues about the policies on midwives.
[Victoria]: Workshops and surveys were held . . . and the dialogues continued until the end of that year, when an extensive report was published, summarizing the requests of the midwives. Among them, that health centers should have personnel who could understand Quiché or other Mayan dialects and who respected their medical practices, such as being allowed to give patients infusions of medicinal plants at the health centers. Also, that they should be allowed to attend patients during the deliveries and that respect for their work would be shown, so that they could, and I quote, “work in unity and without discrimination.”
Other requests were that spaces be adapted so that they could attend to pregnant women, and that they be given an economic stipend for the expenses they incur for deliveries.
The National Policy on Midwives was finally published in 2015.
[Graciela]: I was happy with that policy, but when it came out . . . they were no longer our words. In some instances they were, but in others they were not.
[Victoria]: Among the things that were, was dissemination of the knowledge of the midwives through workshops or talks at health centers. It also stated that the relationship between them and the medical staff should be strengthened, and that midwives should be consulted in decision-making.
However, they felt that the new policy did not cover many of their requests, such as preventing the card from being used to control them, which was one of their main demands. Nor did it include the economic stipend that many had requested, nor did it modify the training, which, according to them, was repetitive and basic.
When she read it, it seemed to Graciela that they had discarded a large part of the conversations they’d had during the round tables.
[Graciela]: Well, once published, it disappointed me. In other words, the Ministry of Health made the policy according to their own desires and whims.
[Victoria]: Although the biggest problem was that the policy was reduced to a manual. It did not have a budget, nor did it have a calendar with deadlines. It only said that in little more than a year, an action plan had to be created to implement those changes.
It seemed to Graciela that, after so much effort, they had made almost no progress.
But that was not entirely true. In other words, they had made some progress: they were organized. And they soon learned that they could take their struggle further. In 2009, the UN had created a Mayan Program to technically and financially strengthen indigenous organizations in Guatemala. Including midwives, of course. And that’s why they were aware of everything that was happening with them.
Graciela found out about this program in late 2015, when she was contacted by an anthropologist who had been working on the development of a legal recourse for midwives.
[Graciela]: “Graciela,” she said, “We are seeing all the discrimination you experience, and a strategic litigation is being set up.”
[Victoria]: She told them that, at that time, the Mayan Program was advising several groups of midwives to file a request for relief directly against the Ministry of Health. Relief, that is, a legal recourse to claim rights that already exist in the law, but aren’t being respected. The issue is that, strictly speaking, the Constitution prohibited discrimination and established that the cultural identity of indigenous peoples should be respected.
When they finished talking, the anthropologist asked if they wanted to be part of the legal process, and the midwives agreed. They decided that Graciela would represent them at the national level. They had to collect all the complaints and demands that they would present in the request for relief. It was a job that took almost a year.
[Graciela]: We went to meetings, we went to human rights, we went to the DEMI.
[Victoria]: To the Ombudsman’s Office for Indigenous Women.
[Graciela]: We went everywhere, to all State agencies for help with the strategic litigation. We had to see the guidelines, we had to see what the law said. It was a never-ending job.
[Victoria]: And she needed money to pay those expenses.
[Graciela]: And then I had to endure hunger because we were not . . . No, we were not earning . . . I was not even earning a salary, and there was no one to pay for my ticket.
[Victoria]: She had to ask her husband for money, and he worked in obtaining leather for shoes and bags. And although it was not ideal, Graciela was sure that what they were doing would be worth it.
[Graciela]: The strong struggle has led us and has helped us also, well, to defend the territories, and one of them is our ancestral wisdom.
[Victoria]: On September 1, 2016, more than twelve thousand midwives from all over the country, legally represented by Graciela, filed the request for relief before the Supreme Court of Justice of Guatemala. In the document they again repeated the complaints they had made so many times: the abuse, the discrimination, the threats. In addition, they demanded that the Ministry comply with what they had requested at the dialogue tables but had been discarded.
What they wanted, deep down, was for Mayan medicine to be valued.
(TELEVISION SOUND BITE)
[Journalist]: These midwives came from different regions of Guatemala to the Supreme Court of Justice.
[Journalist]: Mayan midwives in Guatemala demand recognition of the work they perform within the public health system by attending the deliveries of millions of women in the rural area of that Central American nation.
[Victoria]: Lucrecia Hernández Mack, whom we heard earlier, had been Minister of Health of Guatemala for a couple of months when the request for relief was filed. And although she had not been in office long, she was the one in charge of giving an answer.
[Lucrecia Hernández Mack]: One has to reason about it and understand that the request for relief goes against the minister, but it obviously refers to the entire institution and the historical behavior of the institution. Well, you have to reason about it and understand that all the demands that were being made—well, they were right. And that the institution had failed them.
[Victoria]: With the testimonies and evidence presented by the midwives, the Supreme Court of Justice decided to grant a provisional relief in their favor. In it, they gave the Ministry of Health ten days to report on the measures it was taking to respond to the midwives’ demands.
[Lucrecia]: Everything that had to do with abuse or discrimination we wanted to tackle quickly.
[Victoria]: For this reason, the minister and her team published an official document that ordered health personnel to allow midwives to accompany their patients in all health services. In addition, with the advice of the midwives, they began to work on training the country’s health personnel in Mayan medicine and its practices.
But the request for relief process went on. And since Graciela was the legal representative of the lawsuit, she had to testify before the Supreme Court of Justice on behalf of all.
[Graciela]: It was very difficult to make a decision when they told me to represent them before the Court, because do you know what the first thing I thought was? “Wow, I have to stand before a lot of zopilotes,” I said, “bah . . . “
[Victoria]: She calls the judges of the Court zopilotes because they wear long black capes, which resemble buzzards’ wings. And although it was a little frightening to stand in front of them, she knew how important it was. So, she accepted.
The hearing would be held on February 6, 2017. Graciela prepared for months with the lawyers, to remember everything she had to say.
[Graciela]: And they gave me a document that I had to read and read and read.
[Victoria]: But on the day of the hearing, in the rush to get to court on time, she forgot the document at home.
[Graciela]: So I told them, “You know what? Let me,” I said, “Let me. And I’m going to say what I have to say.”
[Victoria]: She had studied it so much that she felt she knew it by heart.
[Graciela]: I only asked the grandmothers for strength and wisdom.
[Victoria]: The same determination and sense of responsibility that had accompanied her at age 13, when she had to attend her first birth.
When Graciela entered the courthouse, she was wearing a black and white skirt and a woven red blouse with black and white stripes. On her head she wore a bright red scarf, with touches of purple and green. A blanket hung from her left shoulder, and she carried a black rod in her hand, which is a symbol of authority in her community.
[Graciela]: At that point my ovaries had to get stiffer than anything else, because well, I had never stood before a court, you know?
[Victoria]: She was nervous, but started talking.
[Graciela]: I told them: I am standing here before you, honorable magistrates, as the voice of all the more than 23,000 midwives registered with the health system. But at the national level we are more than 90 thousand unregistered midwives as part of the health system. I am here as their voice.
[Victoria]: She told them about the conditions in which the midwives attend births.
[Graciela]: I told them that the grandmother midwives attended births without thinking whether . . . whether it was cold, whether it was hot, whether it was raining, and without seeing how long the trip was, or that they crossed ravines and rocks, or that we went through very dangerous areas.
[Victoria]: She wanted them to understand the commitment they have to their community, in places where the State has never gone.
[Graciela]: That doctors do not go there, where they go. That where maybe a horse manages to go, a midwife gets there to attend the delivery, but doctors don’t.
[Victoria]: Graciela was there to demand they be recognized for their work, their effort and what they went through in providing that care. To say that it was a contribution they gave to the State for free, and in terms of money they saved the State between $900 and $1,200 dollars per delivery. That added up to millions.
She spoke as the voice of her colleagues . . .
[Graciela]: As the voice of the one who is currently attending deliveries, as the voice of the one who is now ill. We are not recognized, I come now to be recognized, the time has come, the times of the grandmothers have arrived, for us to be recognized as iyom.
[Victoria]: Before closing, she said that she hoped the Court would understand them, and that the verdict would be in favor of the midwives. She felt happy.
[Graciela]: Well unburdened, mind you. Pretty relieved, calm.
[Victoria]: Because just being there, standing in front of the judges of the Supreme Court of Justice, felt like an achievement.
[Graciela]: The voice was heard, a voice that for many years, or centuries, had never been so loud here in Guatemala.
[Victoria]: Her voice was heard, but the Supreme Court of Justice, in April 2017, denied most of their claims. They argued that the Ministry was actually complying with what the midwives were requesting and that there was already an existing national policy on midwives. The only thing that was considered pending was the delivery of supplies, so the Ministry had to make a budget to buy and deliver what they requested within 60 days. However, the Ministry appealed, saying it was impossible to do so without knowing how many midwives actually existed in the country.
[Lucrecia]: We did not have a budget to buy kits for 90,000 midwives. And additionally, there was this concern that at the time of delivering kits we were somehow institutionalizing those midwives who perhaps do not want to be institutionalized, right? In other words, they do not want the interference of institutions and Western medicine in their practices and their knowledge.
[Graciela]: It was very sad, you know? But then, at that moment, we said that our fight was going to continue. It’s a challenge that must continue. That’s when we went to the CC.
[Victoria]: To the Constitutional Court. They immediately filed an appeal for the State to respond to all their demands. But they knew it would not be easy. Aside from the recent disappointment with the results of the request for relief, that same year, 2017, President Jimmy Morales had vetoed a law that sought to recognize and grant an economic stipend to all midwives.
At that point, Graciela felt that all the doors were closing on them. Going to the Constitutional Court was one of their last resources.
This is her, in July of that year, in an interview with TeleSur:
(INTERVIEW SOUND BITE)
[Graciela]: Since we have not been heard about . . . about the claim we filed on September 1, so today we come to rectify and ask that we be heard and that the protection that we are asking for be approved.
[Victoria]: But the process would not be resolved quickly. It would be months and months of bringing more documents, going to court appointments, presenting evidence. It was not until March 2019, almost two years later, that the Court ruled in favor of the midwives and ordered the State to immediately begin working on their claims.
But, in practice, changes tend to happen more slowly than in courtrooms. Years of discrimination against midwives and the indigenous population is not something that can be eliminated overnight. Former Minister Hernández Mack told us that it is not a matter of putting out an official letter and waiting for the staff to change their attitude. No. This is a job that requires a budget for training, awareness of the work they do, and real sanctions in place if abuse occurs.
Graciela says that, since they appeared before the Supreme Court of Justice and appeared in the media, she has seen some changes, although minimal, in the health centers and hospitals of Totonicapán.
[Graciela]: When they hear . . . “Who is it, who is asking,” “Graciela Velásquez.” Now, they alert each other, like letting them know, she’s here and now you have to pay attention to her.
[Victoria]: Sometimes, for example, they did let her go inside the hospital and attend her patients. And she has also felt more respect from the health personnel. Although, from what she says, it is not something that happens all the time, because when new nurses, residents, or doctors who don’t know her come in, the mistreatment happens again.
And it has been like this not only for Graciela, but for many other midwives. The Defender of Indigenous Peoples from the Ombudsman’s Office, Bayron Paredes, explained to us that despite the Constitutional Court ruling, the Ministry has not complied with what was ordered. For example, he says they have not hired more medical personnel who speak the same language or provided medical supplies to manage deliveries. According to him, there has been total non-compliance.
Along the way, the national movement of midwives that had been created for the legal claim has also begun to divide, because not all of them seek the same thing. Some want the financial stipend and medical supplies, for example, but others don’t because they fear this will give the ministry more power over them. Such differences are difficult to reconcile.
Despite everything, Graciela feels that the victory, although not complete, did happen: For the first time, their voices were somehow heard.
[Graciela]: The greatest happiness is that at the national level, other sisters were applauding that I had spoken on their behalf. That . . . I only tell you that you must empower yourselves about your rights, learn, and demand too.
[Victoria]: Now there was a ruling from the Constitutional Court that made it permissible to require health personnel, in any center, to respect their Mayan practices.
As for Graciela, she decided to focus on Totonicapán.
[Graciela]: They might close several doors, but I know there are windows, there are roofs to climb, and that is going to be the way to continue on the path.
[Victoria]: Because being an iyom is something that Graciela cannot and does not want to give up.
[Daniel Alarcón]: In late 2020, the Ministry of Health issued a plan to implement the national midwifery policy that had been published six years earlier. So far, tens of thousands of midwives continue to press for an end to discrimination and violence against them and their patients, and for the Ministry to comply with the Constitutional Court ruling.
Through it all, they have continued to support their communities, attending deliveries even during the worst time of the pandemic.
Victoria and Lisette tried to contact the Totonicapán health center and hospital through different means, but received no response.
Lisette Arévalo is a producer for Radio Ambulante. She lives in Quito, Ecuador. Victoria Estrada is a producer in Latino USA and lives in Xalapa, Mexico.
Thanks to Aura Cumes, Bayron Paredes, Magdalena Cholotio and Telma Suchi.
This episode was edited by Camila Segura, Nicolás Alonso and me. Desirée Yépez did the fact-checking. The music and sound design are by Andrés Azpiri.
The rest of the Radio Ambulante team includes Paola Alean, Aneris Casassus, Xochitl Fabián, Fernanda Guzmán, Camilo Jiménez Santofimio, Rémy Lozano, Barbara Sawhill, David Trujillo, Elsa Liliana Ulloa and Luis Fernando Vargas.
Emilia Erbetta is our editorial intern.
Carolina Guerrero is the CEO.
Radio Ambulante is a podcast by Radio Ambulante Estudios, produced and mixed on the Hindenburg PRO program.
Radio Ambulante tells the stories of Latin America. I’m Daniel Alarcón. Thanks for listening.