Amazonian Midwives Are Bringing the Sacred Back to Birth

In November of 2021, a 60-year-old Indigenous midwife from the Sateré-Mawé ethnicity named Miriam de Alencar Pereira accompanied a pregnant woman to the hospital in Maués, a Brazilian town in the interior of the Amazon. “We arrived at the hospital and the labor had already begun. By the time the doctor arrived, the baby had already started coming out,” says Pereira, who has worked as a midwife for 32 years. “The doctor started pulling at the baby’s neck. I intervened, warning that he could kill the baby.”

The doctor told Pereira she had no authority in the hospital, but the midwife held her ground, and the angry doctor stormed out. The baby was born with the next contraction, just as Pereira had predicted. “We wait for the child to come,” Pereira explains. “When the last strong contraction comes, the mother helps, and the baby is born.” Shortly after, nurses arrived wanting to douche the new mother. Pereira again intervened, maintaining that in all her years assisting births in the Indigenous territories, no woman had ever developed an infection after a natural delivery and that the douche was unnecessary. The doctor never returned, Pereira says, not even to check on the patient before she was released.

In Brazil, childbirth is dominated by a technocratic model (a concept introduced by Dr. Robbie Davis-Floyd to describe the role of technology in birth care), and the mode of delivery often tracks socioeconomic and racial disparities, with almost all women undergoing some form of surgical intervention. If you are white and rich, chances are you will have a “cut above,” which refers to a Cesarean. C-sections make up 90% of births in private hospitals, which amount to about 40% of births in Brazil. According to the WHO, this makes Brazil one of the world's leaders in C-sections at 55.7% percent, along with the Dominican Republic (58.1%). C-section rates in the U.S., by comparison, hover around 31.7%, and around 26.2% in the U.K. (still above what the WHO recommends, a rate of 15%). If you are Black or brown or poor, you will probably have a "cut below" referring to an episiotomy, a small cut made at the opening of the vagina during delivery, likely in a public hospital, where 60% of births take place. In a remote region of the Amazon, a group of women are working to change those dynamics, with the hopes of changing the way the entire country views and performs birth.

In 2016, Patricia Mandi left her hometown of São Bernardo do Campo (a municipality of São Paulo) for Maués. She had worked for 10 years in healthcare as a doula and physiotherapist, but had grown disillusioned with what she felt was the sidelining of individualized attention, compassion, and kindness. More traditional modes of care were being replaced with methods and views that exalted technology and profit.

In Maués, Mandi immersed herself in the study of natural birth and healing through Indigenous ancestral practices. Before leaving for the Amazon, she had collaborated with Casa Angela (one of São Paulo’s only public humanized birth centers) and the Instituto Favela da Paz, to help maternal healthcare workers and pregnant women from vulnerable communities access ancestral knowledge and natural birth practices. “I had some serendipitous encounters with Indigenous people who were guiding me to the Amazon,” says Mandi, “and I had dreams that I was going into tents, helping midwives, working with natural medicines and plants, and reconnecting with my purpose—why was I born.”

For thousands of years, Amazonian women have been giving birth in the forest, sometimes alone but usually with the help of a midwife or partner. They traditionally squat, embracing the trunk of a tree and tap into an internal strength. Mandi explains that for the Indigenous Satere-Mawe and Ribeirinho (river people, often intermixed but technically distinct from Indigenous populations), midwives (parteiras) are considered traditional healers (curandeiros) who are blessed with a “gift” imparted by a divine entity. The gift comes with an unspoken code of ethics and the exchange of money is uncommon. Like blessers (benzedeiras) and herbalists (erveiros), midwives cultivate a harmonious relationship between the human and the non-human natural world, serving their community in favor of a collective and accessible model of health care.

While colonization has destroyed many aspects of this culture, most curandeiros continue to resist, quietly safekeeping their knowledge through oral tradition and practice. Increasingly, however, there has been a growing sense that midwifery is more primitive than Western medicine. Many pregnant Indigenous and Ribeirinha women are making the long boat journey from their homes in the interior of the Amazon into cities to deliver at hospitals. Today, midwife assisted home births make up only about 26.4% of births in remote riverside and forest communities in the Northeast and the Amazon, though the number could be greater since many home births go unreported.

Many of the women who make their way to more urban hospitals suffer obstetric violence, a controversial term which refers to everything ranging from neglect to abuse in the pre- and postpartum period. That might include the use of procedures (such as an episiotomy or the administering of IV pitocin) without prior consent; removal of pubic hair; denial of the right to a companion, adequate nutrition and hydration and the freedom of movement during labor. Some women, according to BBC Brasil have also complained about the use of the 18th-century Kristeller maneuver, where the doctor applies pressure to the woman's abdomen to push out the baby. Many studies have proven that the use of such interventions are of no benefit to the birthing woman or her baby and can in fact be detrimental.

Mandi relocated permanently to the Amazon in 2017 to help mobilize a collective for Amazonian midwives into a union that became Mama Ekos. Over the last five years, the collective has developed strategies to promote a natural birth model, empowering midwives and mothers to take back control of their bodies and protect ancestral knowledge. For Mandi, a disconnect between human and non-human nature is echoed within the current maternal health paradigm, where pregnancy and childbirth is viewed as a medical condition and not a sacred experience that is a part of the natural flow of life.

A midwife's work goes beyond the physical aspects of the birth, Mandi explains; midwives are guides and protectors, preparing the woman psychologically and emotionally for labor and motherhood. As Ribeirinha midwife Maria de Fátima Alagoa, who is part of Mama Ekos, explains, “when the woman is in pain, the woman must calm her mind, so that she doesn’t doubt herself about having her baby at home…. When it’s time to push, it’s not me the midwife who will push, but the mother who must have the courage to push her child into the world.”

The Mama Ekos network brings together midwives from different communities for meetings, courses, and workshops. The group also has a radio program to educate on maternal health matters and hosts cultural gatherings to rekindle the traditions of collective artisanal craft-making (beading and weaving) and puxiruns (Indigenous mutual assistance). These events reconnect younger generations with traditional approaches for preparing for maternity and paternity.

“Birth in the Indigenous area is different, because from the first moments we feel the pain of the baby until it is born, the birthing woman stays in our little house,” says the midwife Pereira. “Once the baby is born, we avoid eating foods that upset the stomach. And we stay inside for 30 to 60 days.” That period of time, known as resguardo, refers to a six- to eight-week postpartum period, in which the woman heals and bonds with her baby. Midwives remain for the first eight days, cooking and caring for the mother and baby. Fathers are also included in the resguardo, and when they can’t be present because of work, the trunk of a tree is placed near the baby to represent the father. “Being a midwife is caring for two lives,” says Pereira.

Pereira received the gift “of catching a child” from her father, José Agusto, a fisherman and male midwife (men can also be blessed with the gift). “When he was going to a birth, he always called me,” says Pereira: “Come on! You need to learn, so that when I die I don’t take this with me. One of you must carry on this responsibility.” José Agusto showed her to “puxar a barriga,” a traditional technique to manually guide or rotate the baby into the correct position for birth. This technique has been used for millennia to turn babies who are seated or crossed (lying horizontally), helping to avoid the use of C-sections and other surgical procedures. “I knew it was a gift that came from God,” says Pereira. “I dreamt about births, and when I tried to avoid it people would come looking for me.”

During the final stretch of labor, when the woman is fully dilated and feeling intense pains, midwives often administer a lukewarm cha de managaraitai, a wild Amazonia ginger which is grated into water and drunk as tea. This grated managaraitai is also applied to the laboring woman's belly, often speeding up delivery. Inajá, a palm reed, is used to cut the umbilical cord. Pereira is also an ervorista and cultivates an extensive garden that she considers a natural pharmacy. Like many midwives, she relies on plant-based substances to prevent and treat discomfort and pain. “Whenever I notice that a certain herb is working, I plant more. When I learn about new medicinal plants, I add them to my garden.”

With more than 70 registered midwives, Mama Ekos has become a powerful social movement. Over the years, its activities have challenged established views regarding maternal healthcare in Brazil. Many of the midwives’ own children have now begun writing and documenting their work.

But Mama Ekos continues to face political challenges. Midwife-assisted home births are effectively unrecognized and excluded from Brazil’s National Healthcare System. Midwives do not have access to auxiliary training, basic medical equipment, or financial compensation. In 2019, a bill was introduced to regulate the profession and impose a minimum wage, but it has been stalled since President Jair Bolsonaro came to office three years ago. “We are working to apply pressure so that midwives can receive some assistance,” Mandi says. “When they go to take care of a pregnant woman they use their own gas, sometimes they go without food so that they help feed the pregnant woman and her baby. Why does a nurse or a doctor, have a salary and not a midwife?”

Despite these challenges, the rewards are much greater. “A humanized and ancestral birth for me is a reconnection with nature, with my ancestors, my family,” says Mandi, who hopes that Mama Ekos can become an international reference for natural birth. “It’s a moment of spiritual strength and understanding …a gift so you can finally see the product of your love.”