Indigenous Midwives and the Biomedical System among the Karamojong of Uganda: Introducing the Partnership Paradigm.

Certainly there can be no argument against every woman being attended at birth by a skilled birth attendant. Currently, as elsewhere, the Ugandan government favors a biomedical model of care to achieve this aim, even though the logistical realities in certain regions mitigate against its realisation. This article addresses the Indigenous midwives of the Karamojong tribe in Northeastern Uganda and their biosocial model of birth, and describes the need British midwife Sally Graham, who lived and worked with the Karamojong for many years, identified to facilitate "mutual accommodation" between biomedical staff and these midwives, who previously were reluctant to refer women to the hospital that serves their catchment area due to maltreatment by the biomedical practitioners there. This polarisation of service does not meet that society's needs. We do not argue for the provision of a unilateral, top-down educational service, but rather for one that collaborates between the biosocial model of the Karamojong and the biomedical model supported by government legislation. We show that such a partnership is practical, safer, and harnesses the best and most economical and effective use of resources. In this article, we demonstrate the roles of the Indigenous midwives/traditional birth attendants (TBAs) and show that not only is marriage of the two systems both possible and desirable, but is also essential for meeting the needs of Karamojong women. The TBA is frequently all the skilled assistance available to these women, particularly during the rainy season when roads are impassable in rural South Karamoja. Without this skilled help, the incidence of maternal and infant mortality would undoubtedly increase. Ongoing training and supervision of the TBA/Indigenous midwife in best practices will ensure better care. We offer a way forward via the Partnership Paradigm (PP) that lead author Sally Graham designed in conjunction with the Indigenous midwives and biomedical staff with whom she worked, the development and characteristics of which this article describes.

Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse.

'Medical iatrogenesis' was first defined by Illich as injuries 'done to patients by ineffective, unsafe, and erroneous treatments'. Following Lokumage's original usage of the term, this paper explores 'obstetric iatrogenesis' along a spectrum ranging from unintentional harm (UH) to overt disrespect, violence, and abuse (DVA), employing the acronym 'UHDVA' for this spectrum. This paper draws attention to the systemic maltreatment rooted in the technocratic model of birth, which includes UH normalized forms of mistreatment that childbearers and providers may not recognize as abusive. Equally, this paper assesses how obstetric iatrogenesis disproportionately impacts Black, Indigenous, and People of Color (BIPOC), contributing to worse perinatal outcomes for BIPOC childbearers. Much of the work on 'obstetric violence' that documents the most detrimental end of the UHDVA spectrum has focused on low-to-middle income countries in Latin America and the Caribbean. Based on a dataset of 62 interviews and on our personal observations, this paper shows that significant UHDVA also occurs in the high-income U.S., provide concrete examples, and suggest humanistic solutions.

The Impacts of COVID-19 on US Maternity Care Practices: A Followup Study.

This article extends the findings of a rapid response article researched in April 2020 to illustrate how providers' practices and attitudes toward COVID-19 had shifted in response to better evidence, increased experience, and improved guidance on how SARS-CoV-2 and COVID-19 impacted maternity care in the United States. This article is based on a review of current labor and delivery guidelines in relation to SARS-CoV-2 and COVID-19, and on an email survey of 28 community-based and hospital-based maternity care providers in the United State, who discuss their experiences and clients' needs in response to a rapidly shifting landscape of maternity care during the COVID-19 pandemic. One-third of our respondents are obstetricians, while the other two-thirds include midwives, doulas, and labor and delivery nurses. We present these providers' frustrations and coping mechanisms in shifting their practices in relation to COVID-19. The primary lessons learned relate to improved testing and accessing PPE for providers and clients; the need for better integration between community- and hospital-based providers; and changes in restrictive protocols concerning labor support persons, rooming-in with newborns, immediate skin-to-skin contact, and breastfeeding. We conclude by suggesting that the COVID-19 pandemic offers a transformational moment to shift maternity care in the United States toward a more integrated and sustainable model that might improve provider and maternal experiences as well as maternal and newborn outcomes.

Birthing Between the "Traditional" and the "Modern": DaI Practices and Childbearing Women's Choices During COVID-19 in Pakistan.

Pregnancy and birth are biological phenomena that carry heavy cultural overlays, and pregnant and birthing women need care and attention during both ordinary and extraordinary times. Most Pakistani pregnant women now go to doctors and hospitals for their perinatal care. Yet traditional community midwives, called DaI in the singular and Dayun in the plural, still attend 24% of all Pakistani births, primarily in rural areas. In this article, via data collected from 16 interviews-5 with Dayun and 11 with mothers, we explore a maternity care system in tension between the past and the present, the DaI and the doctor. We ask, what does the maternity care provided by the Dayun look like during times of normalcy, and how does it differ during COVID-19? We look at the roles the DaI has traditionally performed and how these roles have been changing, both in ordinary and in Covidian circumstances. Presenting the words of the Dayun we interviewed, all from Pakistan's Sindh Province, we demonstrate their practices and show that these have not changed during this present pandemic, as these Dayun, like many others in Sindh Province, do not believe that COVID-19 is real-or are at least suspect that it is not. To contextualize the Dayun, we also briefly present local mother's perceptions of the Dayun in their regions, which vary between extremely positive and extremely negative. Employing the theoretical frameworks of "authoritative knowledge" and of critical medical anthropology, we highlight the dominance of "modern" biomedicine over "traditional" healthcare systems and its effects on the Dayun and their roles within their communities. Positioning this article within Pakistan's national profile, we propose formally training and institutionalizing the Dayun in order to alleviate the overwhelming burdens that pandemics-present and future-place on this country's fragile maternity care system, to give mothers more-and more viable-options at all times, and to counterbalance the rising tide of biomedical hegemony over pregnancy and birth.

Pregnancy, Birth and the COVID-19 Pandemic in the United States.

How quickly and in what ways are US maternity care practices changing due to the COVID-19 pandemic? Our data indicate that partners and doulas are being excluded from birthing rooms leaving mothers unsupported, while providers face lack of protective equipment and unclear guidelines. We investigate rapidly shifting protocols for in- and out-of-hospital births and the decision making behind them. We ask, will COVID-19 cause women, families, and providers to look at birthing in a different light? And will this pandemic offer a testing ground for future policy changes to generate effective maternity care amidst pandemics and other types of disasters?

Daughter of time: the postmodern midwife (part 2).

Any effort to make sense of the complexities of contemporary midwifery must deal not only with biomedical and governmental power structures but also with the definitions such structures impose upon midwives and the ramifications of these definitions within and across national and cultural borders. The international definition of a midwife requires graduations from a government-recognized educational program. Those who have not are not considered midwives but are labeled traditional birth attendants. Since there are myriad local names for midwives in myriad languages, the impact of this naming at local levels can be hard to assess. But on the global scale, the ramifications of the distinction between midwives who meet the international definition and those who do not have been profound. Those who do are incorporated into the health care system. Those who do not remain outside of it, and suffer multiple forms of discrimination as a result.

Daughter of time: the postmodern midwife (Part 2)

Any effort to make sense of the complexities of contemporary midwifery must deal not only with biomedical and governmental power structures but also with the definitions such structures impose upon midwives and the ramifications of these definitions within and across national and cultural borders. The international definition of a midwife requires graduations from a government-recognized educational program. Those who have not are not considered midwives but are labeled traditional birth attendants. Since there are myriad local names for midwives in myriad languages, the impact of this naming at local levels can be hard to assess. But on the global scale, the ramifications of the distinction between midwives who meet the international definition and those who do not have been profound. Those who do are incorporated into the health care system. Those who do not remain outside of it, and suffer multiple forms of discrimination as a result.

Qualquer esforço para dar sentido à complexidade do processo reprodutivo na vida contemporânea se depara não só com o modelo biomédico e as estruturas governamentais de poder, mas também com as definições que tais estruturas impõem às parteiras e obstetrizes e à sua denominação, considerando-se os limites nacionais e culturais. A definição internacional de parteira demanda a formação em instituições de ensino reconhecidas pelo governo. As parteiras tradicionais não podem ser consideradas parteiras, mas são denominadas parteiras tradicionais. Há uma gama enorme de denominações para as parteiras em diversos locais, nas diversas línguas e ao longo do tempo, que torna difícil nomear este profissional. Entretanto, em escala global, pode-se reconhecer que há duas ramificações de parteira: a que está incorporada ao sistema de saúde e a que está fora dele.

Cualquier esfuerzo para dar sentido a la complejidad del proceso reproductivo en la vida contemporánea se depara no solamente con el modelo biomédico y las estructuras gubernamentales de poder, sino con las definiciones que estas estructuras imponen a las parteras y matronas y su denominación considerándose los límites nacionales y culturales. La definición internacional de partera demanda formación en instituciones de enseñanza reconocidas por el gobierno. Las parteras tradicionales no pueden ser consideradas parteras, pero son denominadas parteras tradicionales. Hay una gama enorme de denominaciones para las parteras, en diversos locales, en las diversas lenguas y a lo largo del tiempo, y por eso es difícil nombrar a este profesional. No obstante, en escala global se puede reconocer que hay dos ramificaciones de partera: la que está incorporada al sistema de salud y la que está fuera de él.

Daughter of time: the postmodern midwife (Part 1)

This article presents the notion of the postmodern midwife, defining her as one who takes a relativistic stance toward bio-medicine and other knowledge systems, alternative and indigenous, moving fluidly between them to serve the women she attends. She is locally and globally aware, culturally competent, and politically engaged, working with the resources at hand to preserve midwifery in the interests of women. Her informed relativism is most accessible to professional midwives but is also beginning to characterize some savvy traditional midwives in various countries. Thus the concept of the postmodern midwife can serve as a bridge across the ethnic, racial, and status gaps that divide the professional from the traditional midwife, and as an analytical focal point for understanding how the members of each group negotiate their identities and their roles in a changing world.

Este artigo busca conceituar a parteira pós-moderna, definindo-a como aquela que tem uma postura realista em relação à bio-medicina e a outros sistemas de conhecimento, movendo-se fluidicamente entre eles para ajudar as mulheres que assiste. É consciente, culturalmente competente e politicamente engajada. Trabalha com recursos do seu conhecimento específico, aliados aos interesses da mulher. Seu relativismo informado é mais acessível para as parteiras profissionais, mas o que se observa, ao redor do mundo, é que esta atitude está atingindo as parteiras tradicionais, em diversos países. Assim, o conceito de parteira pós-moderna representa uma ponte para as brechas étnicas, raciais e de status, que separam as parteiras profissionais das tradicionais, e um ponto focal e analítico para a compreensão da forma de negociação de identidades e papéis de cada um dos membros no grupo, no mundo em transformação.

Este artículo busca conceptuar la partera pos-moderna, definiéndola como aquella que tiene una postura en relación a la biomedicina y a otros sistemas de conocimiento, moviéndose fluidificado entre ellos para ayudar a las mujeres que asiste. Es consciente, culturalmente competente y políticamente enganchada. Trabaja con recursos de su conocimiento específico, aliados a los intereses de la mujer. Su relativismo informado es más accesible para las parteras profesionales, pero lo que se observa, alrededor del mundo, es que esta actitud está atingiendo las parteras tradicionales, en diversos países. Así, el concepto de partera pos-moderna representa una puente para las brechas étnicas, raciales y de status, que separan las parteras profesionales de las tradicionales, y un punto focal y analítico para la comprensión de la forma de negociación de identidades y papeles de cada uno de los miembros en el grupo, en el mundo en transformación.

Daughter of time: the postmodern midwife (part 1).

This article presents the notion of the postmodern midwife, defining her as one who takes a relativistic stance toward biomedicine and other knowledge systems, alternative and indigenous, moving fluidly between them to serve the women she attends. She is locally and globally aware, culturally competent, and politically engaged, working with the resources at hand to preserve midwifery in the interests of women. Her informed relativism is most accessible to professional midwives but is also beginning to characterize some savvy traditional midwives in various countries. Thus the concept of the postmodern midwife can serve as a bridge across the ethnic, racial, and status gaps that divide the professional from the traditional midwife, and as an analytical focal point for understanding how the members of each group negotiate their identities and their roles in a changing world.

Why do women go along with this stuff?

PREFACE: Normal childbirth has become jeopardized by inexorably rising interventions around the world. In many countries and settings, cesarean surgery, labor induction, and epidural analgesia continue to increase beyond all precedent, and without convincing evidence that these actions result in improved outcomes (1,2). Use of electronic fetal monitoring is endemic, despite evidence of its ineffectiveness and consequences for most parturients (1,3); ultrasound examinations are too often done unnecessarily, redundantly, or for frivolous rather than indicated reasons (4); episiotomies are still routine in many settings despite clear evidence that this surgery results in more harm than good (5); and medical procedures, unphysiological positions, pubic shaving and enemas, intravenous lines, enforced fasting, drugs, and early mother-infant separation are used unnecessarily (1). Clinicians write and talk about the ideal of evidence-based obstetrics, but do not practice it consistently, if at all. Why do women go along with this stuff? In this Roundtable Discussion, Part 2, we asked some maternity care professionals and advocates to discuss this question.

Home-birth emergencies in the US and Mexico: the trouble with transport.

Proponents of the global Safe Motherhood Initiative stress that primary keys to safe home birth include transport to the hospital in cases of need and effective care on arrival. In this article, which is based on interviews with American direct-entry midwives and Mexican traditional midwives, I examine what happens when transport occurs, how the outcomes of prior transports affect future decision-making, and how the lessons derived from the transport experiences of birthing women and midwives in the US and Mexico could be translated into improvements in maternity care. My focus is on home birth in urban areas in Mexico and the US. In both countries, biomedicine and home-birth midwifery exist in separate cultural domains and are based on distinctively different knowledge systems. When a midwife transports a client to the hospital, she brings specific prior knowledge that can be vital to the mother's successful treatment by the hospital system. But the culture of biomedicine in general tends not to understand or recognize as valid the knowledge of midwifery. The tensions and dysfunctions that often result are displayed in midwives' transport stories, which I identify as a narrative genre and analyze to show how reproduction can go unnecessarily awry when domains of knowledge conflict and existing power structures ensure that only one kind of knowledge counts. This article describes: (1) disarticulations that occur when there is no correspondence of information or action between the midwife and the hospital staff; and (2) fractured articulations of biomedical and midwifery knowledge systems that result from partial and incomplete correspondences. These two kinds of disjuncture are contrasted with the smooth articulation of systems that results when mutual accommodation characterizes the interactions between midwife and medical personnel. The conclusion links these American and Mexican transport stories to their international context, describing how they index crosscultural markers, and suggest solutions, for "the trouble with transport."