Authorizing tradition: vectors of contention in Highland Maya midwifery

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Authorizing tradition: vectors of contention in Highland Maya midwifery Servando Z. Hinojosa* Department of Psychology and Anthropology, University of Texas-Pan American, Edinburg, TX 78541, USA

Abstract In Guatemala, midwives deliver the majority of children and play an important health care role in rural areas. Maya midwives, using time-proven methods, are the chief providers of care for mothers and infants in these areas. In recent decades, however, the medical establishment has become interested in Maya midwives, and is currently engaged in training and certifying many of them. This study examines how Guatemalan health authorities have sought to change Maya midwifery, refashioning its vocational framework and retooling it in accordance with Western medical principles. I focus on the place of obligatory formal training and the use of biomedical materials in the experience of Kaqchikel Maya midwives, and consider how the health officials employ these means to undermine the midwives’ knowledge base. Encounters between midwives and formal health personnel reveal an ongoing privileging of biomedical knowledge, one that preserves asymmetrical relationships between these practitioners. This creates an environment favorable to health personnel, and helps them to extend their influence through the midwives into the community. Given this, I contend that health personnel value local Maya midwives primarily for their role in furthering the goals of biomedicine. r 2003 Elsevier Ltd. All rights reserved. Keywords: Guatemala; Maya midwifery; Biomedical change; Maternal health; Child care

Introduction This article examines how formal health personnel have taken an interest in Maya midwifery in Guatemala, and how they consider it to need official control and licensure. By mandating formal midwife training and using biomedical materials as part of this control process, the health establishment has linked the legitimating of midwives with institutional compliance. Of interest to this study is how the resulting ideological tensions and technological changes in the local health scene reveal the establishment’s efforts to undermine the midwives’ knowledge base. Health authorities have tried weakening the midwife’s confidence in her abilities and replacing her practices with biomedical ones. In doing so, they further the official view of Maya midwifery as a vehicle for reaching a wider public. Midwives and health officials of San Juan Comalapa, Guatemala, have interacted for decades, but always in *Tel.: +1-956-316-7002; fax: +1-956-381-3333. E-mail address: [email protected] (S.Z. Hinojosa).

an environment privileging biomedical knowledge. Nonetheless, in this municipality of some 28,380 people, divided between a town center and 27 surrounding villages and hamlets, midwives remain the chief caregivers to pregnant women. Fewer than five out of one hundred births are attended, on average, by physicians each year. Those births that are attended by physicians are usually referred by midwives. This situation has prompted physicians and other formal health workers to reassert their influence over childbirth practices in ways that have heightened existing ethnic and institutional tensions. Comalapa’s population consists almost entirely of Kaqchikel Mayas. This group is characterized locally by different degrees of Kaqchikel-Spanish bilingualism and by the wearing of woven blouses and skirts by females. Townspeople rely heavily on small-scale maize agriculture for meeting subsistence needs, but many also produce vegetables and textiles for export, especially to the US. Many Mayas practice a synthesis of Roman Catholic and Maya religious observances known as costumbre, a set of traditions mindful of, among other

0277-9536/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2003.11.011

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things, spirit-owners of the natural world upon whom humans depend. These observances are disavowed by Indian converts to local Protestant groups who nonetheless feel that natural and supernatural forces do affect human lives. Another key feature of the local setting, and partly related to Protestant conversion, is the assimilation process whereby Kaqchikel Mayas grow to identify with a national Guatemalan culture centered upon Western values and Spanish language use. Two outcomes of this process are the prioritization of Spanish as a home language and the abandonment of native dress by women. Less apparent is the declining emphasis on use of Maya health practitioners such as soul-therapists, bonesetters, and midwives. Mayas who undergo this become identified as Ladinos, members of the cultural group comprising approximately half the Guatemalan population. Children of Ladinoized Maya seldom learn a Maya language or identify as Maya. Guatemalan Ladinos occupy a structurally advantageous position over Indians. Not only do they tend to have a higher income than Mayas and benefit from operating solely in the national language of government and education, Spanish, but they concentrate in places where formal health services are located: urban and semi-urban areas. The providers of these services, in turn, come largely from Ladino backgrounds. This situation has often disfavored Indians in terms of affordability, treatment, and inter-ethnic regard (Acevedo & Hurtado, 1997, p. 272; Cosminsky, 1982, p. 240). To a large extent this is true of the Comalapa formal health landscape. Different public and private groups have participated in building a medical infrastructure in Comalapa, which is largely under the control of nonIndians. Central among local facilities is the government Health Center where a plurality, if not the majority, of health seekers go for subsidized care. The Center is staffed by one physician, one professional nurse, and about eleven auxiliary nurses. The private Hospital K’aslen functions with an attending physician and a mixed nursing staff. Also found are several private clinics operated by physicians, a NGO clinic with a contracted physician and dentist, and two ambulatory NGO physicians who visit outlying settlements. At least two church-based weekend clinics operate locally, as do about nineteen pharmacies and seven health posts in surrounding villages visited by the occasional physician.1 Comalapans visit these facilities seeking different services, sometimes after seeking treatment from noninstitutional healers, or in conjunction with these. Clinic 1 Physicians working in Comalapa generally aspire to open their own local clinic, but until they do they expect to spend a few years working for the Hospital K’aslen, the NGOs, or even a church. One physician opened a clinic adjoined to his family’s pharmacy, apparently without first working for other entities or before finishing university.

personnel have been known to rebuke their Maya patients for not arriving sooner or for visiting healers. The interaction declines further in quality when clinic personnel try dealing with persons with limited knowledge of Spanish. While many health workers do speak Kaqchikel, they have difficulty conveying concepts known primarily in Spanish to persons unaccustomed to biomedical care expectations (see Hinojosa, 1994a). Training sessions for midwives take place under these conditions, primarily in the Health Center. There, health personnel and midwives interact in ways favoring Spanish speakers and Western health concepts, continuing the tense state of relations between formal and nonformal practitioners.

Methodology This study is interested in the perspectives of midwives and formal health practitioners, particularly physicians, as they relate to how Maya midwifery has been subjected to biomedical legitimation and change. Participants were selected over the course of long-term ethnographic fieldwork. I interviewed six midwives during this study, primarily in 1992, 1995, and 1996, and kept in contact with one in later years. Five assistants interviewed nine additional midwives in 1996. During these years, I also interviewed and interacted with seven local physicians, and interacted with several nurses, auxiliary nurses, and health promoters. I learned of specific local midwives through personal acquaintances and the Health Center. I did not go directly to those recommended by the Center, but to those my acquaintances, and later my assistants, knew. This helped to prevent interviewing only of women considered ‘‘certified’’ by the Center, and did not have the effect of under representing in the study midwives with official training. I did not intend to randomly interview all local midwives, but to contact midwives of different cultural, vocational, and religious backgrounds through personal referrals and to try reaching greater depth in the work of a few of them. Midwives with different formative experiences and perspectives were thus contacted. Information resulting from these encounters was later complemented by material gathered by interview assistants in 1996. Fortunately, all midwives approached by myself and my assistants agreed to provide information for this study. To learn of the midwives’ experiences and of how they operate in the local professional environment, I conducted structured and semi-structured interviews with them. We met in their homes, and generally spoke for an hour at a time. I was directly introduced to at least three of the midwives by personal acquaintances, and following two of these introductions my acquaintances

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remained present during the first interview. The remaining midwives were met by referral. I met twice with three of the six midwives, and with the remaining three I met at least six times between 1992 and 1996. One was revisited in later years. The encounters took place largely in Spanish with five of the six midwives; a Kaqchikel speaker aided with the sixth. Throughout the interviews many ritual questions and details were addressed in Kaqchikel. Data were recorded in Spanish and Kaqchikel in written form. Five bilingual female assistants, literate in Spanish and Kaqchikel, interviewed nine additional midwives in the last six months of the study. I oriented the assistants on the purposes of the study and reviewed useful interview and discussion techniques with them. I also provided them with notebooks and a set of guidelines for organizing their interactions with midwives. The assistants were urged to consider the guidelines, consisting of 59, mostly open-ended items, as starting points for discussion, rather than as fixed questionnaires. They were encouraged to engage the basic ideas of these guidelines in the manner, pace, and language preferred by the participants. The guidelines covered the areas of interest I had been addressing with other midwives. Most of the interactions led by assistants took place in Kaqchikel, especially those with older women. Each guideline-based interview took approximately three hours to complete, typically over two visits to the midwives’ homes. No recording devices were used. Interviewers recorded their data in written Spanish and Kaqchikel. Of contextual importance to this study were the perspectives of formal health practitioners. Between 1991 and 1996 I interviewed and conversed with seven physicians working in Comalapa, six of which were male. Most worked in Comalapa only, while others divided their time between out-of-town and local clinics. I was personally introduced to two of the physicians and I sought out the remaining five in their clinics and homes. Among the physicians were Mayas and nonMayas, Comalapans and non-Comalapans, and Catholics and Protestants. Structured and semi-structured interviews took place in their clinics, their homes, and in my home. Throughout the 1990s, I also conducted semistructured interviews with approximately five nurses, auxiliary nurses, and health promoters in their workplaces and homes. In all cases, Spanish was the medium of speech and notes. Following each interview I conducted with a midwife or formal health practitioner, I reconstructed as much as possible from my notes about the encounter. Midwife data from assistants’ interviews were reviewed, clarified as needed, and transcribed. Information from both sets was transliterated into English, while some illustrative passages were kept in the original Spanish or Kaqchikel. Data from all interviews were transcribed and compiled

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during the research itself, allowing me to follow up on recurrent or unusual themes in the interviews. Certain midwives were thus asked to elaborate on specifics they brought up, for which reason not all midwives discussed the same points in detail. A potential limiting factor in the study was the use of female assistants who were unmarried and childless. Moreover, the latter two conditions also characterized me, a male. Midwives may have felt it inappropriate to discuss matters of pregnancy and birth with us, and may have withheld information. However, the midwives interviewed seemed quite forthcoming with their knowledge. I believe this to be the case for two main reasons: one, non-midwife women whom I have known for several years and who I consider friends described to me their pregnancies and births in great detail, providing information from which I then built midwife interview guides. Midwives acknowledged the categories of experience noted in the guides, elaborated upon them (refuting them at times), and occasionally brought up new categories. And two, non-midwife women later corroborated much of what midwives reported, while noting that some of the midwives’ arcane experiences were unfamiliar to them. This study underscored how a qualitative approach can be useful when considering the experience of midwives in a single community. By conversing with midwives and physicians over a period of years, I observed how they regarded each other, and even their own peers, and made changes to their own practices in response to practices of the other group. Family and inter-ethnic dynamics also became evident over time, particularly as they concerned hierarchical relationships in health care. An extended view of midwives and physicians brought into focus how the encounter between them has been anything but smooth. The biomedical regime has made it necessary for midwives to change their approach to childbirth and relinquish some of their supervision of it, despite the importance of midwives to maternal-infant health.

The midwife’s working environment Not unlike the case of midwives in other developing countries, midwives in Guatemala are indispensable to national health care. The Pan American Health Organization (PAHO) reports that in Guatemala, only 29 percent of births are attended by medical professionals, whereas 60 percent of births are attended by comadronas, midwives (PAHO, 1994 II, p. 224). Both Maya and Ladina (cultural non-Maya) women seek the aid of midwives, although Maya women more often enlist them as their sole caregivers (Glei & Goldman, 2000, p. 17). Midwives bear heavy birth care responsibilities; other factors of local life add to these.

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Guatemala is a largely rural country, approximately 65 percent so (PAHO, 1998, II, p. 294). However, only 20 percent of all health services are located in the rural areas (Painter, 1989, p. 6). Residents of Guatemala City, in contrast, constituting 25 percent of the national population, have access to approximately 80 percent of all health services (Painter, 1989, p. 6). Medical personnel, including 80 percent of all physicians and over half of all nurses, are likewise concentrated in metropolitan areas (PAHO, 1998, II, p. 302). In the 1980s this resource skewing coincided with a 33 percent higher rural than urban mortality, and with an Indian mortality 50 percent higher than that of non-Indians (PAHO, 1986, II, p. 126). The country’s leading causes of death are preventable infections of the upper respiratory tract and conditions originating in the perinatal period (PAHO, 1998, II, p. 295). Gastrointestinal infections and nutritional deficiencies are the next leading causes of mortality, and take an especially heavy toll on children. This incidence of disease is accompanied by high rates of infant mortality, reaching 48.3 in 1994 (PAHO, 1998, II, p. 295), and maternal mortality, estimated at 190 between 1990 and 1995 (PAHO, 1998, II, p. 296). Because of underreporting of maternal deaths, though, the adjusted maternal mortality rate is actually much higher, reportedly 270 for this period (WHO, UNICEF, & UNFPA, 2001, p. 38).2 An alarming degree of malnutrition presents among children below age 5. Between 1988 and 1990, the prevalence of acute malnutrition tripled in this group (PAHO, 1994, II, p. 225–226). The same study revealed a weight deficit among 25.7 percent of urban children under three and among 36.6 percent of rural children under three (PAHO, 1994, II, p. 226). The difference between non-Indian children and Indian children under three is marked, as well: 28.6 percent of non-Indian children exhibit a weight deficit, whereas 40.6 percent of Indian children do (PAHO, 1994, II, p. 226). If a child survives his first year of life, he will likely face severe nutritional stress for several more years, especially if he is rural and Indian. This is part of the burden Maya midwives shoulder in their largely rural settings. They witness children dying of diarrheal dehydration in the rainy season and of persistent coughs in the dry. For all her efforts in delivering the child safely, the midwife cannot be sure the child will survive his first month of life; she sees many that do not and are buried quietly. Midwives work in an environment that medically disfavors the rural poor and Indians. Nevertheless, these women are the chief means by which Maya women can deliver healthy

babies and survive childbirth, something that greatly interests Guatemalan health planners.

Formal training The Guatemalan health establishment recognizes that Maya midwives are in close touch with maternal and pediatric health needs in rural areas, where most Guatemalans live. Since 1935, an official mandate has existed for providing training to established midwives, with the aim of orienting them in urban-based birthing physiology and the use of Western birthing instruments (Greenberg, 1982, pp. 1604–1605; Lang & Elkin, 1997, p. 26). Through the Ministry of Public Health’s Article 98 the state hoped to monitor ‘‘empirical’’ health workers and keep a closer watch on rural birth and death rates. It wanted to achieve this through midwives who were already enmeshed in local society. But this initiative existed in name only for years, with midwife training programs beginning in 1948 in Totonicap!an and in 1976 in San Marcos (Greenberg, 1982, pp. 1604– 1605). The training programs sought to exploit the midwives’ integration into local health care, but have had mixed results. Re/making the midwife Despite their operational difficulties, though, midwife training programs have affected many midwives. Today, a large number of midwives throughout Guatemala and Mexico have attended official ‘‘trainings’’ (Castan˜eda Camey et al., 1996; Greenberg, 1982; Jordan, 1989; Woods & Graves, 1973). Midwife training is also evident in Comalapa, where it seems to have been taken up in earnest just before or immediately after the 1976 earthquake. Many midwives have since received training, but the exact number of trainees varies with the source of information. A few ‘‘official’’ figures come from local health personnel. A physician who studied local midwives cited a preliminary 1995 Comalapa Health Center report asserting the presence of 25 registered midwives (Roquel, 1995). A comprehensive 1995 Health Center report (Health Center, 1995), meanwhile, noted 44 registered midwives in Comalapa’s town center and surrounding villages. This number decreased to 37 in 1996, according to a Center administrator. However, Clemencia, a registered midwife, stated that in 1996 at least 60 comadronas practiced locally.3 She was evidently aware of midwives unknown to the Center. In 1999 and 2000 the number of midwives affiliated with the Center increased to 58 in each year, and reached 79 in 2001

2

The reader should be aware that these are national figures that conceal huge differentials between rural and urban populations and between Indians and non-Indians.

3 All participants in this study, with the exception of Elva Marina Roquel Cal!ı, are identified by pseudonyms.

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(Health Center, 1999, 2000, 2001). Officials made great efforts to recruit women for midwife training as the decade unfolded, although the women recruited were nearly all already working midwives. The reported number of midwives varies within and between time periods, revealing two things: one, that the state has been unable to keep a close eye on midwifery work, and two, that the very term ‘‘midwife’’ is hotly contested. By its very nature, midwifery is embedded within complex social networks (Day, in press). Health officials, knowing little about these networks, are poorly equipped to count and observe working midwives. They retain much influence, though, in arbitrating who can be called a midwife. For officials, a midwife can only be someone who has received formal training, whereas for a midwife, she may be a woman who has either received training or who has proven herself through much practical experience. If present trends continue, however, more midwives and other people may eventually restrict the term, comadrona, to women with formal training. Midwives and the general public are moving toward the medical establishment’s view of what a midwife is. This is evident in the manner in which more women are actively seeking training and licensure from health authorities. Whereas before, many women became midwives through a process of practical experience and divine election (see Paul, 1975; Paul & Paul, 1975), now, more women are pursuing midwifery skills through official channels. This trend received a tremendous impetus following the 1976 earthquake. Many Comalapans recount the arrival of North Americans who established the Hospital California next to the town center. This hospital afforded local women a look at formalized patient care and at the use of Western medical materials. By most accounts, Hospital California was the first local facility to conduct widescale training in basic clinical and preventative care. It is also remembered as the means through which many midwives first received formal training opportunities. Gabriela remembers how she enrolled in health promoter training at Hospital California. One day during her affiliation with the hospital, and when physicians were unavailable, a woman about to give birth approached her. Gabriela took her to the hospital, but a nurse said the woman was experiencing false labor. Gabriela then brought her to her pharmacy and helped the woman deliver. Impressed with her work, hospital personnel recommended her to the Health Center for a year and a half of midwife training. Following this, Gabriela was sent to a 2-week practicum in Mazatenango. Similarly, Eva received training in health care at the hospital. Long interested in nursing, she had studied it through a correspondence course but lacked practical experience. During her 2 years at the hospital, she

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gravitated toward midwifery, but knew local women could not assist in childbirth there. Once, however, when a woman needed to deliver, and no physicians were around, Eva was allowed to help. After the hospital closed, Eva continued training in midwifery at the Health Center, and eventually received permission to practice. Like these women, Celedonia was interested in midwifery. She was a mother and had assisted in other women’s births. Unsure about her calling, though, she did not affiliate with the hospital. In the years following the earthquake, she again grew interested in midwifery and was placed on a waiting list for training at the Center. But when her turn came up, Celedonia hesitated and did not to go. Six months later, she learned of another course at the Center, and finally attended. After a 2-week course, she received her certification. While not all practicing Comalapa midwives have had formal training, all the midwives my assistants and I spoke with had had some contact with trainers. Even the oldest midwife interviewed, Sarita, who was 88 when I spoke with her in 1992, remembered attending courses at the Health Center, the Casa de la Cultura (a civiceducational center), and at a local hospital, albeit when already well into her career. The high incidence of training participation among the interviewed midwives attests to the formal sector’s intent to equip rural Guatemalans in community health. Since few urban-trained health professionals choose to work permanently in the countryside, the state has conceded to certifying rural health promoters and midwives. Still, as we have seen with the slow implementation of the midwife certification legislation (Article 98) and with the above health figures, the state has not prioritized rural health. Progress was made in the late 1960s, but it took the attention produced by the 1976 earthquake and foreign agencies to prompt the state to respond to deteriorating health conditions (Hurtado & S!aenz de Tejada, 2001, pp. 216–217). The earthquake became a window of opportunity for advancing public health measures, primarily by disseminating urban health approaches to the countryside and by accelerating foreign advisorship. As Green (1989, p. 254) points out, though, these foreign-derived health inputs were implemented in ways that did not threaten underlying structures of inequality and resource allocation. In Comalapa, the social aftershocks of the earthquake were dramatic, also, for as the town rose from the rubble, a biomedical vision of midwifery strengthened. The vision of midwifery promulgated by national and local health planners, though, has not been without shortcomings. A major limitation of the program has been its uncritical acceptance of Western medical principles. Western principles of obstetrics and midwifery, some quite unfamiliar to local women, are imported into the local experience, where they sometimes collide with traditional norms (see Kelly, 1956). In

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the process, an asymmetrical relationship emerges between trainers and midwives, with trainers privileging their own biomedically derived belief system over that of local midwives. The didactic teaching method, wherein information flows unilaterally from instructor to student, unaccompanied by practical instruction, is widely employed in training sessions. Jordan (1989, p. 931) notes how this method also prevails in official midwifery courses in Yucat!an, and how it ignores the way traditional midwives acquire their skills experientially, by ‘‘going around’’ with an experienced midwife, and not by sitting passively and being authoritatively ‘‘taught’’ (Jordan, 1989, p. 928). One reason didactic teaching has been ineffective, regardless of content, is because relatively few adult Maya women have had long-term schooling. Of the 25 midwives interviewed by Elva Marina Roquel for her medical thesis, 76 percent were illiterate (1995, p. 21). This figure concords closely with a 1989 study revealing illiteracy at 74 percent among Guatemalan Indian women over age 15 (compared to a rate of 34.2 percent for all Guatemalan men over 15) (PAHO, 1994 II, p. 222). Since Roquel’s sampled midwives derive from social conditions shared by most Comalapan women of their age group (30–79), the midwives’ illiteracy figure likely holds for most local women of this age group. Ironically, this widespread female illiteracy is the chief reason health planners endorse oral teaching and explanation. By providing trainers who can stand and deliver official views of health care, the Ministry of Public Health reasons it can circumvent the problem of illiteracy and reach trainees through a shared medium: speech. Training programs remain unresponsive to the practical needs of midwives, though. Instead of encouraging midwives to think creatively and experiment with different therapeutic techniques appropriate to their patients, trainers (and physicians) want midwives to adhere to pre-established guidelines. But what the health establishment lacks in pragmatism it tries making up for by conferring a greatly valued item: the vocational credential. When I met with midwives, they sometimes showed me either a certificate or a carnet (pocket license), which was earned by attending midwife training sessions. Celedonia displays her framed certificate recognizing Adiestramiento de Comadronas Tradicionales, ‘‘Training of Traditional Midwives.’’ She has difficulty reading the rest of the certificate, but explains that it certifies her to work openly. The certificate is curiously worded, speaking of ostensibly ‘‘training’’ someone already recognized as a midwife, or of ‘‘training’’ someone for a traditional role. Gabriela keeps her bright pink, walletsize carnet in her woven blouse with her other valuables. She unfolds it, tripling its size, and points to her picture on one panel and to her name on another. It shows an issue date of 7 January 1995, and is due for annual

renewal in one month at the Health Center. The carnet signifies her satisfactory completion of many trainings and her permission to work locally. The acquisition of such a permiso, work authorization, marks an important moment for both the midwife and the Health Center. For the midwife, she can rest assured that, so long as she abides by the tenets of the trainings, or keeps a low profile when she does not, she can legally perform as an ambulatory midwife. For the Center, to authorize a midwife means that she can be monitored and called upon to share insights with other midwives. That is, she can share insights that agree with the Center’s teachings. Issuing a permiso also affords the Center another control mechanism over midwives: if midwives are suspected of non-compliance with Center objectives, the Center can threaten to revoke their work permits, as also occurs in other communities (Acevedo & Hurtado, 1997, p. 319). Certified midwives are also expected to look out for other local midwives who have not yet received training. When a certified midwife learns of a midwife practicing without a permiso, she notifies the Health Center. The Center then contacts the uncertified midwife and invites her to a training session. With this ‘‘invitation,’’ the midwife is legally obliged to attend the training. According to the Ministry of Public Health’s Article 99, the legislation accompanying Article 98, though, if a duly invited midwife does not report to the training, she is considered ‘‘unauthorized’’ to practice (Greenberg, 1982, p. 1604). It generally behooves midwives to attend the training and later refresher sessions, because many clients take comfort in a midwife’s successful reputation, often made possible only through an open, legal practice. Most certified midwives try maintaining their relationship with the Health Center, even when they consider the trainings professional formalities. For the most part, as Cosminsky (1982, p. 238) points out for K’iche’ midwives, the act of, ‘‘Receiving ‘scientific’ or ‘modern’ training and a license as an additional qualification is adaptive in accommodating to the demands of the official medical system.’’ Midwives know that a license will allow them, at very least, to practice openly. Midwives who evade training and licensure know they risk censure, but for many, this simply means they should keep a low profile and, preferably, work away from the town seat where the Center is less vigilant (Cosminsky, 1977, p. 73). As the midwife Clemencia implied in 1996, numerous midwives probably elect this covert modus operandi. When a midwife does submit to training and certification, she will likely find herself listening to hours of instruction from Health Center personnel and visiting professionals. Local staff, including a professional nurse and several auxiliary nurses, usually comprises the trainers, although a few midwives mention that

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physicians (especially the predecessor of the current attending one) have taught in the past. Most current certified midwives participated in training sessions lasting 2 weeks. Midwives who received certification after the mid-1990s had to attend a 4-week long training. This was last offered in 1996, according to the Center. In the trainings, locally known as adiestramientos, several standard topics are covered, including general hygiene, basic information on pregnancy and birth, and the arrangement and use of the midwife’s instruments (Greenberg, 1982, p. 1605). Trainers also employ illustrated charts of the kind found taped to the walls of rural health centers, showing how to boil water to avoid contamination, how to build latrines away from water sources, etc., in some lessons. Once certified, midwives must return to the Health Center for periodic refresher courses, but, personnel disagree on how often these courses are supposed to be held. In 1995, a staff member informs me that midwife trainings are held every month at the Center. Another staffer, meanwhile, admits that although midwives are supposed to attend monthly workshops, the Center has not offered them recently. She tells me in November 1995 that only one training session has been held in the current year, in January; she assumes the next one will be in January 1996. The Center currently (2002) holds midwife refresher courses every other Thursday, although these often conflict with the midwives’ schedules. The Comalapa Health Center’s attending physician, Dr. M!endez, explains that trainers use Spanish when instructing midwives. He does not consider this a problem for monolingual Maya-speaking midwives because, he says, an assistant translates material into the Kaqchikel ‘‘dialect.’’ In his view, Spanish-speaking individuals with biomedical training can communicate effectively, directly and indirectly, with persons for whom Spanish is not a first language and who may be unfamiliar with the public health and obstetric tenets put forth in the training. Midwives recall how much of what was taught in the sessions had to be relayed through the nearest available bilingual person. Whether or not vital information is lost or altered in this process is difficult to know, but it happens sufficiently often to raise questions about the quality of communication between trainer and trainee (Hurtado & S!aenz de Tejada, 2001).4 4 Given the didactic teaching format and the difficulties with instructional language, it is remarkable that as many women complete and remain with the training programs as actually do. Their affiliation is still more remarkable considering that many midwives attend training against their husbands’ wishes. Clemencia says that when she attended training, many of her peers’ husbands protested that their wives were ‘‘neglecting their housework.’’ Many men made their wives leave the classes

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Midwives who navigate the didactic training and language barriers, and who remain affiliated with the Center, still face institutional opposition to several aspects of their work. Worse still, in the process of ‘‘improving’’ midwives’ technical repertoires, health officials often scold and reprimand those midwives who perform unapproved procedures (Acevedo & Hurtado, 1997, p. 318). Witnessing this elsewhere, Cosminsky (1977, p. 74) relates, ‘‘Not only is there no accommodation to local customs, but the instructors take a condemnatory and condescending attitude toward (midwives)’’ (see CCAM, 1990, p. 91). As midwives are forced to question key elements of their work, a process of selection, alteration, and concealment of these elements is put into motion. Elements under fire Several elements of midwifery have been targeted by biomedicine. Trainers routinely single out the practices of external cephalic version, use of the sweatbath for maternal care and delivery, the kneeling or squatting birth position, and the practice of post partum binding. To differing degrees, each of these practices has been censured by officials in Comalapa, as in other communities (Acevedo & Hurtado, 1997, p. 320; Cosminsky, 2001a, p. 203). Comalapan midwives consider prenatal massage central to their work. They apply their hands to women’s abdomens to determine the size of the uterus and fetal position, and perform versions when they think necessary. Midwifery trainers regard external cephalic version with indifference at best and criticism at worst. Because biomedical personnel in Guatemala are seldom apprised of the usefulness of prenatal massage and versions, performed widely by Guatemalan midwives (Goldman & Glei, 2003, p. 694), they frown upon their use by midwives. The Health Center is especially suspicious of versions because they happen in the place to which the Center has little access: people’s homes. Health authorities of Yucat!an also discourage the practice among Maya midwives; midwives there have learned to simply not admit to performing it to trainers (Gu! . emez Pineda, 1988, p. 12; Jordan, 1989, p. 929). Despite growing support for the safety and usefulness of external cephalic version (Ranney, 1973; Jordan, 1984), trainers are unlikely to endorse the procedure anytime soon. Nonetheless, while Comalapan midwives will continue performing prenatal massage, they may grow (footnote continued) and forego certification. Opposed to this and other expressions of midwives ‘‘unseemly behavior,’’ midwives’ husbands in other Guatemalan communities have also objected to the demands of the midwife role (Douglas, 1969, pp. 145–146; Paul & Paul, 1975, p. 715).

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reluctant to perform versions as biomedical supervision intensifies. Pre- and postnatal massage is traditionally tied to use of the sweatbath, tuj or temascal, which is itself discouraged by health authorities. Historically, the tuj has been used for bathing and childbirth by Mayas and other Middle American peoples and is closely associated with midwives’ work (Groark, 1997). It is regarded as the ideal place for postnatal heating and massage of the mother’s breasts to stimulate milk flow (see also Cosminsky, 2001b, p. 353). Today in Comalapa, when a midwife is off at her daily examination rounds, people say of her, ‘‘She went to do a tuj.’’ In some Maya communities a midwife is even called ajtuj, ‘‘She of the sweatbath.’’ Comalapan health authorities, however, charge that the tuj is unsanitary and implicated in the high incidence of infectious diseases afflicting rural groups. Birthing use of this structure has also been discouraged in places like San Lucas Tolima! n and Santa Luc!ıa Utatl!an (Woods & Graves, 1973, p. 7; Cosminsky, 1982, p. 238). Current attacks against the tuj are heirs to colonial-period sanctions against it. Colonial and religious authorities were outraged to find that families would bathe together in the tuj’s darkened interior (Moedano, 1961, p. 43; Villatoro, 1986, p. 3). Modernday authorities continue acting with suspicion toward this home resource. But while not all Comalapan midwives use the sweatbath today, those who do use it are unlikely to abandon it in the near future.5 Reflecting what Jordan (1989, p. 927) calls the ‘‘invisibility of the indigenous obstetric knowledge system for the medical staff,’’ Comalapan physicians, nurses, and other health personnel also oppose the traditional kneeling or squatting birth positions. They claim that, with these positions, the child descends with too much force and can become stuck inside the mother or be expelled onto the ground. Although these fears are unfounded, health personnel continue forbidding trained midwives from allowing these positions and instead mandate the supine (lying flat on back) or lithotomy (lying on back with knees raised) positions (Cosminsky, 1982, p. 238, 1977, p. 73; Greenberg, 1982, pp. 1601, 1606). In one community, San Miguel Pochuta, health trainers discourage midwives from allowing squatting births and instead instruct them to use the ‘‘semi-reclining’’ position, one neither fully sitting nor supine (Lang & Elkin, 1997, p. 27). Health personnel there and in Comalapa warn that traditional birthing positions will create problems too great for 5 Following the 1976 earthquake, very few Comalapan houses or tuj were left standing. In subsequent reconstruction efforts, most houses were rebuilt, but many tuj were not. Consequently, not all homes in Comalapa today have a tuj, and those that do are much more likely to use it for pre- and postnatal massage than for birthing.

midwives to handle. As a result, some Comalapan midwives require clients to use the supine position; otherwise, the midwives refuse to attend them, as is also reported in Santa Luc!ıa Utatl!an (Cosminsky, 1982, p. 242; see Cosminsky, 2001b, p. 356). Health authorities mandate use of horizontal birth positions without critically examining why. Instead, they teach midwives to fear birthing in any other way. Increasing medical evidence, however, points to the advantages of ambulation in labor, which include decreased pain (Melzack, Belanger, & Lacroix, 1991), reduced need for analgesia and uterine stimulants (Flynn, Kelly, Hollins, & Lynch, 1978), and shortened duration of labor (Shin-Zon, Aisaka, Mori, & Kigawa, 1987). Jordan reviews how the lithotomy position, in contrast, ‘‘causes contractions to become weaker, less frequent, and more irregular and makes pushing harder because increased force is needed to work against gravity... making forceps extraction more likely and increasing both the need for episiotomy... and the likelihood of tears because of excessive stretching of the perineal tissue and tension on the pelvic floor (Jordan, 1993, p. 85).’’ Also to the detriment of the child, lithotomy birth decreases the size of the pelvic outlet and negatively affects the mother’s pulmonary ventilation, blood pressure, and cardiac return, thereby lowering oxygen to the fetus (Jordan, 1993, pp. 85–86). Ironically, a Comalapan physician complains that midwives are not doing enough to conserve the mother’s strength during labor. Dr. Serech claims that comadronas sometimes ask the parturient to push too hard for too long, leaving her tired and unable to expel the placenta. If the lithotomy position were used as often as physicians wish it were, though, there would likely be much more birthing exhaustion of the kind he blames on Maya midwives. The fourth major feature of traditional midwifery health officials frown on is post partum abdominal binding. Midwives often wrap a length of cloth around the mother’s lower abdomen to return moved ‘‘bones’’ back into place and to support the uterus as it resumes its non-pregnant size. The binding is said to help the mother return to her pre-gestational figure more quickly. Widespread use of post partum binding among Maya and other groups underscores the popularity of this practice (Goldman & Glei, 2003, p. 696; Jordan, 1993, pp. 43–44; Paul, 1975, pp. 458–459). Health authorities, however, consider it of little value and discourage it (Gu. e! mez Pineda, 1989, p. 8; Greenberg, 1982, p. 1604). But since the binding is applied following birth, authorities level fewer criticisms against it than against external cephalic version, use of the tuj, and squatting or kneeling birth. In repeated instances, health trainers disparage features of the midwives’ work they neither understand nor care to evaluate. Trained midwives who retain

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traditional, but contested, features of midwifery must conceal these from health authorities in order to remain certified. Midwives unknown to the Health Center, on the other hand, face no immediate penalty for performing banned procedures, and are freer to use them.

Biomedical materials At the same time that the Health Center prohibits certain procedures and items, it actively promotes others. The Center is especially insistent on having midwives use approved midwifery instruments. These instruments are adopted in an environment increasingly favoring biomedical elements, and one in which physicians seek control over pregnancy, birth, and professional knowledge and status. Instruments of change I first viewed the midwifery toolkit in Celedonia’s home in 1992. As proud as she was of her midwife certificate, Celedonia was even prouder of the items she kept in a covered enamel pot. She removed each item in the kit and explained its use: scissors for cutting the cord; a scale, of the type used in fishing tackleboxes, for weighing the newborn; a rubber bulb for extracting fluid from the newborn’s nose and mouth; a wrap for the newborn; cloth ties for the umbilical cord; and the pot itself, in which everything is stored and in which the bulb and scissors are boiled before use. In 1999 she updated her toolkit with an item she did not initially like, rubber gloves. The Health Center urged her to use these, but she feared their slipperiness would make her drop the newborn. More useful to her were the umbilical cord clamp and pincers she acquired a year later. She, like other midwives, though, has had to purchase these items herself. It has taken her a while to do so since her husband’s alcoholism and death strained her family finances. Midwifery toolkits are similar throughout the highlands, with some variations in their contents. Certified midwives in Chichicastenango, Totonicap!an, and San Marcos, for example, keep plastic sheeting in their kits to place beneath the parturients (CCAM, 1990, p. 65; Greenberg, 1982, p. 1606). In addition, some midwives tote extra washbasins, towels, soap, and sections of cloth, the latter used to bind the infant’s abdomen and umbilical stump (Lang & Elkin, 1997, pp. 27–28). Although trainers have tried standardizing the use of scissors for cutting umbilical cords, many midwives cannot or do not use them. They have sometimes used other objects like sickles, knives, razor blades, or machetes. For Celedonia scissors are good not only for cord-cutting but also for emergencies; if the newborn emerges with the amniotic membrane covering his head,

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she uses the scissors to cut it away.6 Split cane, once widely used for cord-cutting, has been largely replaced by metal tools in Comalapa, following decades of condemnation by health authorities.7 For tying the cord, trained midwives routinely use commercial sterile ribbon such as Lavacinta. Guatemalan midwives deal with umbilical stump asepsis in different ways. More traditional ones cauterize the stump with a candle, while others disinfect it with alcohol or Merthiolate (Cosminsky, 1982, p. 243); one traditional K’iche’ midwife, open to effective biomedical measures, does both (Cosminsky, 2001b, p. 354). Comalapan midwives combine one of these methods with an abdominal binder, placed on the umbilical stump. Most trained Comalapan midwives try incorporating these standardized instruments and features into their work while still adhering to some central elements of Maya midwifery. Home sobada visits, home births, and spiritual counsel are elements many certified midwives seemed to be conserving in the community. At least one local midwife, however, wants to maximize her use of medical instruments and expand her practice along Western lines. Eva has grown interested in establishing a sala de maternidad, maternity clinic. With such a clinic, she says, she could keep all her equipment in one place and conduct her examinations and deliveries on site. Eva observes that, ‘‘The conditions in which people live are pathetic,’’ and argues that she can control for hygiene if she centralizes her operations. But the goal of having a successful clinic will not be easily reached, she admits. 6 In most cases, the sac will rupture shortly before the infant’s head emerges, freeing the head from breathing obstructions. A midwife must know, however, what to do if the child emerges still enveloped by the sac. Celedonia, kneeling at her backstrap loom as we spoke, explains that if the infant’s head is covered by the sac, she must act quickly to free it. To illustrate her procedure, she reaches into a basket where she keeps balls of thread. She places a large ball of thread inside a clear cellophane bag and explains that a covered head appears much like this. The midwife must pinch away a bit of the slippery sac from the neck of the infant (away from the head and face) and cut it with scissors. Scissors must be used, she stresses, for the membrane is very strong. When the incision is made, the head is carefully uncovered, permitting the child to breath; the rest of the body can then be uncovered. When the child emerges with its bolsita, little sac, it is described as Petenaq . xti ruq’uj xti rutzyaq, ‘‘It is emerging/nearing covered up in its clothes.’’ 7 One midwife explained that the umbilical cord should not be tied (and cut) prematurely. She cautioned that the midwife should wait five minutes before cutting the cord, to minimize danger of bleeding. Midwives know umbilical bleeding must be prevented, and explain that they apply the cloth ties tightly. This admonition to wait five minutes, and the readiness with which midwives explain their cord-tying and, now, pincer using, practices, implies that the midwives interviewed generally cut the cord before the placenta has exited the body.

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Among the impediments to this is the reluctance of local women to going to clinics, in the first place, and the cost of supplies. She remembers how, at Hospital California, medical supplies were disposable, so there was no need for equipment resterilization. However, since Eva cannot dispose of her supplies, she must find ways to resterilize and reuse them. Her solution is to acquire a sterilization machine. Local health officials encourage respect for Western medical equipment among trained midwives, but not Eva’s kind of clinical ambition. Already concerned about competing patient patronage, health officials also worry that a structurally subordinate category of healthworkers, midwives, might aspire to structural equivalence with the formal sector. For this reason formal personnel periodically remind midwives of the limits of their practice. Formal personnel position themselves as the arbiters of which midwifery elements should be authorized and which discarded. As part of this endeavor, the Health Center occasionally censures midwives who openly disregard its mandates. One such midwife who draws attention to herself is, not surprisingly, Eva. It turns out that Eva is not only keen on equipment, she is also keen on administering injections. Although health promoters are permitted to administer certain injections, midwives are usually not, unless they are also trained health promoters. The Health Center is most concerned that midwives not inject birthing women with anti-hemorrhage drugs or with oxytocin, a hormone which stimulates uterine contractions, used to hasten delivery of child and placenta (Klein, 1995, p. 378). She has been told not to administer these drugs, regarded as potentially dangerous by Western health workers (Neuberg, 1995; WHO, 1997). Eva’s continued use of them, as well as her involvement in two maternal deaths, has resulted in suspension of her certification. She continues practicing, however, ignoring summons from the Center. Eva’s case is one in which the midwife becomes ostracized by her licensing body for approximating its methods too closely. Health personnel consider injections and IV solutions their province and reprimand women found to administer them. With some exceptions, the Health Center’s enforcement power over midwives involved in ‘‘transgressions’’ is limited to revocation of certification, and the threat of this, alone, is generally enough to assure overt compliance. As we see with Eva, however, threats and revocations act to increase distrust between midwives and their certifiers. Midwives and trainers have agreed upon the use of certain other pharmaceutical products. Trained midwives are expected to apply protective eye drops to the newborn, to ‘‘clean the eyes,’’ as Gabriela puts it. Another midwife, Clemencia, uses oral rehydration salts provided by UNICEF and distributed by the Health Center for treating children’s intestinal tract infections.

Midwives also encourage mothers to take vitamin tonics, and remind them to vaccinate their children against tetanus, whooping cough, tuberculosis, and measles. The midwives’ role in the latter is critical, as many mothers fear vaccinations. Physicians and biomedical prioritization As accommodating as midwives are to the pharmaceutical side of biomedicine, they sustain an uneasy relationship with physicians. Judging from the manner in which midwives speak of physicians and from personal observation, it is evident that midwives limit their contact with them and avoid them outside of training contexts. If a midwife senses a problem with a client, however, she might send her to Dr. Me! ndez at the Health Center or to a private physician. Pregnant women also limit their contact with physicians. As a result, in the mid-1990s physicians dealt with only one percent of births in Comalapa, according to Drs. Su!arez and Cun. The percentage of medically attended births has since increased from 1.98% in 1998, 3.17% in 1999, 7.3% in 2000, to 4.24% in 2001 (Health Center, 1998, 1999, 2000, 2001). Physicians argue that, despite low usage of their services, the opportunity exists for far greater numbers of pregnant women to seek physicians. The circumstances under which medically attended births often occur, though, worsen relations between midwives and physicians. Comalapa physicians report that midwives often bring them emergency obstetric cases. Dr. Serech says that the only times midwives bring him patients is when patients are suffering from a retained placenta or hemorrhage, or when the newborn has problems. ‘‘At the most, I attend one per month and then only when there’s a complication,’’ he says. Physicians abjure dealing with these emergencies, what they call doing the ‘‘repair’’ work of midwives. The midwife Eva admits that when her patients suffer perineal tears, she has no choice but to seek a physician’s help, even though she knows the physician will rebuke her. If she finds a physician who will help, he will only do so resentfully, all the while chiding Eva for ‘‘mishandling’’ the pregnancy. Other physicians resent being awakened at a late hour by a midwife urging him or her to attend to a woman unknown to the physician. Physicians say they usually turn away pregnant women who approach them in a late stage of pregnancy, telling the women that they will only attend patients who have been under the physician’s control, monitoring, for their entire pregnancy. They direct these women to the Health Center. If the Center is closed for the day, the midwife will have to either find the attending physician at his home, search for another physician in town, or take the woman to the department capital. Significantly, physicians firmly tell midwives to not send for them if there is a complication in the births

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the midwives are handling. Midwives are told to bring their patients to the physician in time for thorough prenatal monitoring, and not at the last minute. To illustrate why he is wary of women in crises appearing on his doorstep, Dr. Serech shows me a glass jar he keeps on an office shelf. The jar contains a tiny human fetus, which he preserved from a time when a woman came to him suffering a miscarriage. The physicians’ concern in childbirth is for more than simply the good outcome of the cases. As physicians put it, they are greatly concerned about their prestigio, public prestige. Comalapa physicians are forthright about this point and sometimes harbor bitterness toward midwives and mothers who might endanger their reputation. Dr. P!erez recounts how a family asked him to treat a dying baby, but, knowing that the child would die, he advised them of this and gave the child only symptomatic treatment. He stopped short of scolding them, but expressed exasperation to me over how the family performed a costly baptism meant to save the child. To have taken on the case would have been a no-win situation for him and would have brought desprestigio, tarnished prestige, he says. He and other physicians are less forgiving with midwives, whom physicians consider better informed in health matters than the general public. Physicians do not want to be blamed for an infant or maternal death, particularly when a midwife brings the case. As part of their concerted effort to avert desprestigio stemming from problem births, physicians follow specific labor guidelines. Dr. Serech explains how, with normal labor, from the earliest light contractions, the cervix should reach ten centimeter dilation within 24 h. If full dilation is not reached in this period, Serech sends the woman to the Health Center or a hospital. He adds that, sometimes, although the cervix reaches full dilation, confirmed by vaginal palpation, the bones of the woman’s pubis do not ‘‘open’’ sufficiently. When this happens, he says, ‘‘The product doesn’t descend, that is, the fetus doesn’t come down,’’ producing severe fetal stress (see Jordan, 1997, p. 66). Here, again, the woman will be referred out. This approach stands in contrast to that of many midwives, who generally allow for a longer labor period, especially for primiparas. It is also at variance with Western nurse-midwifery and obstetric guidelines (Varney, 1980, p. 171; Neuberg, 1995, p. 186).8 Some Comalapan midwives expect primiparas to 8 Unlike Dr. Serech who times the progress of labor from the earliest light contractions, Western practitioners pay closest attention to the period following the start of active labor, marked by a cervical dilation of 3–4 cm and by the onset of longer and stronger contractions. A 24 h time limit for all births could reduce the time allowed for active phase labor and would not take into account differences in likely active phase labor time between primiparas and multiparas.

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be in labor for more than one day and will not seek invasive medical intervention until they have attempted non-invasive techniques first. Physicians, however, consider the latter method tedious, risky, and just one more way midwives mishandle labor. They also fault the way they perceive midwives to deal with asepsis. Dr. Su!arez takes this criticism to a comical extreme. One day, while explaining midwives’ alleged carelessness with germs, he mimicks how a midwife attends a birth, cuts the cord with a pair of scissors, wipes the scissors off on her blouse, and hurries off to another birth to cut another cord with the same dirty scissors (Hinojosa, 1994b, p. 49). Aside from reasons of proximity, familiarity, and respect, economic reasons also motivate many women to prefer midwives over physicians. A comparison of midwives’ and physicians’ fees for childbirth attention highlights the enormous cost differential between these two groups. In 1992, physicians such as Dr. Su!arez charged anywhere from $55.50, $74.00, $92.60, to $166.70 for clinical exams and deliveries. The increasing costs reflect births of increasing levels of difficulty. Deliveries at the local private Hospital K’aslen, meanwhile, cost from $15.00 to $18.50, or much more if complications were present. In 1996, Dr. Serech’s fees started at $108.00. The midwife Mercedes confirms that during this period, physicians would routinely charge from $50.00, $83.30, to $166.70, according to case difficulty. These costs are additional to prescription and other expenses. In comparison, midwives in 1996 would generally charge from $0.83, $4.20, to $8.30 for prenatal, delivery, and postnatal attention. This includes sobadas, baths, bindings, counsel, and the time needed to walk to the client’s home to perform these services. The client’s family often provides meals for the midwife during her visits, as well as other gifts of liquor or chocolate. She receives small payments of money over the course of the pregnancy. When delivery nears, or immediately after, many midwives help with home chores such as cooking and washing clothes, activities health trainers find ‘‘unbecoming’’ in certified midwives. Given these advantages, it is not surprising that most women enlist comadronas for pregnancy care, and defer their concerns over unforeseeable birth complications. One behavior that midwives are increasingly finding in common with physicians, though, is selectiveness towards clients. As mentioned above, midwives are reluctant to accept women in the middle to later stages of pregnancy, especially primiparas. They are also known to refuse women with signs of problem pregnancies. Midwives, however, invoke prestigio less often than do physicians, although it does concern them. Once they have selected their clients, though, many midwives now routinely refer them out for care, whether

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or not the case is within the midwives’ capacities. The propensity to make referrals is due in the short term to midwives’ compliance with official ‘‘recommendations,’’ but ultimately derives from the way health authorities tacitly and overtly encourage Maya midwives to question their own diagnostic and management abilities. Constantly reminded of their limitations, trained midwives are taught to believe that their vocational skills are insufficient for pregnancy and childbirth and that they must accede to the official knowledge of biomedical personnel. Biomedical personnel make clear that knowledge must flow from those who ‘‘know’’ (themselves) to those who ‘‘don’t know’’ (midwives) (Acevedo & Hurtado, 1997, p. 317). The cases of Gabriela and Eva show how this works. When Gabriela would conduct an initial screening of a potential client, she would determine whether the woman was likely to have a problem pregnancy. But, regardless of her assessment, Gabriela would then send the woman to the Health Center for further examination. Because of her Center training, she was convinced that she might have overlooked something. Eva, meanwhile, had had professional difficulties with the Center, but she still looked to formal health personnel for the final word in pregnancy cases. Her dissatisfaction with Center personnel, though, prompted her to recommend that all her clients visit a gynecologist in the department capital, Chimaltenango. If a client needed a local health worker, Eva would send her to the Hospital K’aslen, and not to the Center.9 Clinical referrals have been standard for her since she began working. In these and other cases, the trained midwives’ growing dependency on the medical establishment can be observed. One consequence of this is an increasing tendency by midwives to downplay their knowledge of procedures and situations that they were formerly capable of handling, including external cephalic version and even reduction of an inverted uterus (see Huber & Sandstrom, 2001, p. 169). It has not been easy for midwives to persuade women to visit clinics as part of their new imperative, but health facilities have assisted by trying to keep fees low. Dr. P!erez says clinics must charge a fee, though, even if a symbolic one, so patients will feel they are receiving quality care. To attract maternity patients, clinics in 9 Elsewhere in the Maya highlands, Chichicastenango midwives also tend to take many or all their clients to the local Health Center. As one midwife puts it, ‘‘For me it is better to take them all because it is necessary, since the doctor has instruments he can use and check the pregnant woman’s condition’’ (CCAM, 1990, p. 84). Another Chichicastenango midwife recommends taking women to the Health Center so that the personnel there will be partial to her should any problems arise with a given woman’s delivery (CCAM, 1990, p. 85).

Guatemala sometimes also offer free food and medicine to women (Cosminsky, 1982, p. 241; CCAM, 1990, p. 85; Greenberg, 1982, p. 1606). An NGO clinic in Comalapa likewise distributed food and home items to persons attending health education sessions. Disbursement ended, though, when the directors decided that the provisions were the only attraction for attendees. With its unsteady annual budget, the Health Center has also been unable to maintain permanent food and medicine disbursement for maternity patients. Even when clinics provide modest enticements for women, other more basic factors inhibit usage of these facilities. A frequently cited factor is the unwillingness of many women to be examined by male physicians, an objection echoed by husbands and even mothers-in-law (Cosminsky, 1977, p. 82; see Metzger & Williams, 1963, p. 221). Men sometimes allow their wives to consult physicians only if accompanied by a midwife, something not all midwives can arrange (CCAM, 1990, p. 88). These demands of modesty vex physicians like Dr. P!erez. He explains how, by 1992, after 3 years of practice in Comalapa, he had delivered only two children. One woman he attended told him that her verguenza, shame . and embarrassment, would ever cause her to cover her face when encountering him in public. The problem, it turns out, is not simply of a clash of male and female worlds. A Comalapan female physician, a Kaqchikel Maya, has also encountered problems when attending to birthing women, problems relating to her familial status. Dr. Roquel recounted how late one night in Comalapa, a man summoned her to attend his wife. When Roquel arrived at their home, the woman decided she did not want Roquel’s help. ‘‘She basically rejected me,’’ Roquel said, because Roquel, although married, had no children and was therefore disqualified from assisting at a birth. In the end, though, the woman accepted Roquel. On another occasion, after assisting in a delivery, Roquel was asked by the mother to kiss the newborn. When asked why, the mother replied that since Roquel was married, then she was surely with child, and being with child, she had surely given the newborn mal de ojo. This condition can be transmitted by reportedly ‘‘envious’’ expectant mothers to infants. Roquel said she would kiss the child later, once it was cleaned up. Roquel’s difficulties are intertwined with a larger problem facing health workers in Guatemala. In its decision to train greater numbers of midwives (and female physicians), the Ministry of Public Health has been recruiting women whose life conditions would make a midwife vocation for them untenable under normal conditions. By allowing unmarried or childless women to work in midwifery, the health establishment is effectively putting a culturally inappropriate category of woman up for the job. A locally acceptable midwife would be someone who is older, married, a mother, and who has helped other women give birth. Her reputation

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would have grown from her successful empirical experience, especially if she had received a divine mandate to practice. While these conditions are not true for every Comalapan midwife, they recur in the lives of many. According to the midwife Clemencia, though, women as young as ages 15–18, often childless, have been registering for comadrona courses at the Health Center. Of those registered, she says, very few have worked before as midwives (see Cosminsky, 1982, p. 239; Greenberg, 1982, pp. 1606–1607; Tedlock, 1992, p. 38). What does this mean for midwives and physicians wanting to assist in pregnancy and delivery? For one, it should remind them that pregnant women expect them to be experienced as adults and parents. Female physicians are especially bound by these prerequisites. The health worker’s life conditions matter as much as his or her sex for determining whether he or she can attend births. When midwives and physicians do not measure up to public expectations, they can expect difficulty in attracting clients. They will be positioning themselves poorly within a system that, for the moment, allows clients some choice between different health workers.

Discussion This article has explored how the Maya midwife is situated vis-"a-vis a biomedical culture that has great need of her, but remains hostile to her work. In view of how health officials set out to change the midwife’s work and consider it a window for public health intervention, I contend that health officials are interested in midwifery only inasmuch as it can further their own objectives. To do this, health officials have enacted a system designed to cast in doubt the midwives’ knowledge and gradually supplant it with biomedically sanctioned knowledge, knowledge with an authoritative basis that precludes other ways of knowing (Cosminsky, 2001b, p. 370; Jordan, 1997). Health officials have had more success changing specific practices of midwives than their actual knowledge, but for officials, the outcome is the same: enactment of methods in line with their goals. The chief vectors through which biomedicine has achieved its entry into midwifery, and of primary interest to this study, are the certification mandates for midwives and the use of biomedical materials by these. While much information is provided to midwives in formal trainings, the methods used to convey it impede its delivery. It is unlikely that the didactic teaching method, or the use of interpreters, communicates as effectively as health trainers expect. One shortcoming of the trainings is that they privilege knowledge from foreign and urban medical contexts and wield it over local midwives for whom it may have limited relevance.

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Midwives elsewhere often react to this instruction by outwardly agreeing with trainers and developing a facility with biomedical language, appearing to acquiesce to health officials (Gu! . emez Pineda, 1989, p. 12; Jordan, 1989, p. 928; Lang & Elkin, 1997, p. 30). Throughout these trainings, however, trainers undervalue the native vocational preparation for midwifery. They also overlook the potential of a multilateral approach, one weighing the merits of traditional midwifery and using empirical methods to impart skills. Increased use of biomedical materials, in the form of birthing kits and pharmaceuticals, is very evident among midwives. Midwives are widely familiar with analgesics, vitamin tonics, antispasmodics, and even antibiotics, available without prescriptions from pharmacies. Some midwives use other preparations, including oxytocics, although they sometimes come under fire from officials for this. Overall, one sees a pattern of material inclusion and experimentation, inspired, interestingly, by health workers’ confidence in these products. Cosminsky and Scrimshaw (1980) have noted elsewhere in Guatemala how healers (Maya and non-Maya) have incorporated some aspects of cosmopolitan medicine. They write, ‘‘(healers) are using certain aspects of the physician’s role as their model, and thus acknowledging and reinforcing his prestige. However, it is primarily the technology and pharmaceuticals that they have adopted, reflecting both their own and their clients’ faith in those aspects of Western medicine’’ (Cosminsky & Scrimshaw, 1980, p. 275). Use of these products may help midwives appear ‘‘modern’’ in a society that looks with approval at signs of modernity among health workers. Of course, use of these materials by untrained persons can be dangerous (Acevedo & Hurtado, 1997, p. 298; Goldman & Glei, 2003, p. 697; Schwarz, 1981, p. 59). As the medical terrain changes in Guatemala, changes can be expected in Maya midwifery, as well. Some of these changes will involve discernible elements like certifications, palpations, birthing positions, birthing kits, fees, case referrals, and engagement with family planning. With respect to the latter, Maya midwives have already found themselves in especially challenging positions (see Metz, 2001; Ward, Bertrand, & Puac, 1990, 1992). Other changes in midwifery will be less apparent. A strong possibility exists that, as midwifery comes under the growing influence of biomedicine, its spiritual dimensions will be deemphasized. This may take a subtle form at first, with midwives transferring more childbirth cases to physicians, undermining what Celedonia calls, ‘‘the don [gift] of the hands.’’ Likewise, with increasing exposure to biomedicine, Maya midwives might view the biomedical model of conception as the only viable one, and disavow their models of divine animation in the womb (see Hinojosa, 1999, pp. 190–191).

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Midwives are the health resources most preferred by Guatemalan women for dealing with pregnancy and birth. Their usage is especially high in indigenous communities where midwifery has long provided women with physical and other forms of care. Health officials in San Juan Comalapa maintain relationships with Maya midwives in hopes of reaching a clientele to which they otherwise have limited access. They are affording themselves a platform through which continued health interventions can be made. The effects of these interventions, as well as of the disparagement of midwife ways of knowing underpinning them, will be felt first by indigenous mothers and children.

Acknowledgements I would like to thank the many midwives, laymen, and families who helped me during my stays in San Juan Comalapa. The staff at the Comalapa Health Center and town physicians were most helpful. This research was assisted by funds from a UCLA Department of Anthropology Research Grant and a National Science Foundation Graduate Fellowship. Judith M. Maxwell and Victoria R. Bricker were continual sources of support.

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