Midwifery in Jamaica
British imperialist thought and institutions have systematically erased the cultural values of indigenous Jamaican practices surrounding birth. During the Atlantic slave trade, Jamaica was a hub of import for enslaved Africans forced into the farming and production of cash crops on plantations. During this time, the nana, the Jamaican folk midwife, was the primary birth attendant for women.
Her prevalence was increased by the colonial governments lack of regard for women’s health and children’s well-being. However, the late 19th century showed development of public health laws and regulations and the colonial government started to generate policy that encouraged hospital practices to include birth attendance.
This push to medicalization erased the knowledge of the nana, previously an important authority figure in the community, and convinced women of the legitimacy of knowledge monopolized by medical professionals. Women then put their trust in the biomedical professionals.
However, a decline in the economy in the late 20th century showed the lack of integrity in Jamaica’s maternal care. Hospital birth attendance became increasingly dysfunctional and dangerous. Maternal morbidity and mortality increased due to avoidable factors.
In 2013, the European Union joined a financial agreement with the Jamaican government to spearhead PROMAC, a program that aims to reduce child mortality and improve maternal health. The program has introduced new trainings, technology and science to Jamaica.
However, according to the standards set forth by Davis-Floyd et al., Jamaica currently has a birthing model that is not functioning at its fullest potential by remaining loyal to biomedical professionals and ignoring and disrespecting indigenous practices and knowledge. The risk of a totally dysfunctional maternity system looms as history threatens to repeat itself.
The Nana in Jamaica
The traditional birth attendant, the nana, managed all aspects of birth for mothers throughout Jamaica’s history. Her title has its roots in the Twi language of the Akan people of Ghana and Ivory Coast. It is a term to describe a grandmother, an elder or venerable ancestor. The nana, rooted in collectivistic culture of understanding the cycles of life and birth, provided cohesion in the social networks in Jamaica.
In the villages, the nana is a person that possesses wisdom and authority. This term crafted in the Twi language made its journey across the Atlantic along with the men and women lied to and forced to leave their homes to work on plantations. This wisdom was passed down orally throughout years of experience and family apprenticeship, from mother to daughter.
The nana is an extension of the mother. She is present through a young woman’s transition from conception to birth, animating the rebirth of the woman as a mother through rituals. Jamaican nanas would stay with mothers for nine days after they had delivered their child. She would inform the mother of ways to avoid postpartum complications.
Wise words from the nana would reintroduce new mothers to postpartum life and everyday routine. Her role was paramount to peaceful transitions throughout the cycles of life for Jamaican communities but her authority was a threat to colonial power to control the Jamaican population.
Her wisdom was actively silenced by British colonial sentiments and policy eradicating their role under the guise of public health initiatives. When the shipments of enslaved people decreased, colonial plantation owners became more invested in the reproduction of the Jamaican population.
1867–1874 showed development of public health laws and regulations in the wake of cholera and smallpox epidemics. To decrease the vectors of disease, the colonial government funded training of “respectable women of good character” to fill the roles of healthcare practitioners in hospitals.
British officials generated policy that extended hospital duties to include birth attendance, which discredited home deliveries and eradicated the indigenous practices of the nana by pushing the medicalization of birth and the biomedical authority of knowledge of wellbeing.
Women were convinced of the legitimacy and superiority of knowledge monopolized by the colonial government. There was a stark transition from the veneration of the nana to neglecting her knowledge in favor of the medical assistance of nurse midwives.
Birth Delivered in a Hospital
Birth became a life event that required medical attention. Mothers began to turn to community midwives that were trained in basic obstetric care and to refer patients to hospitals. When they were far enough along to deliver, the mothers would be assisted by hospital nurse midwives.
However, women’s dependence on nurse midwives became increasingly dangerous as a decline in Jamaica’s economy created a dysfunctional maternity system within the hospital from 1987–1989. The economic decline exacerbated by International Monetary Fund and World Bank structural policies led to cutbacks in health services and cuts in salaries for health professionals.
The following discussion will be geographically situated around Victoria Jubilee Hospital in Kingston, Jamaica. The women living around this hospital were exposed to unjust living conditions. Their houses were constructed of scrap metal and access to clean water and nutritious food was rare. The nana, once an important authority figure respected for her wisdom and experience through times of hardship, was no longer a resource for women.
The economic decline did not put a halt to the birth of a new population. The number of births still occurred but in hospitals that were overcrowded, understaffed and undersupplied. Waiting rooms lined with benches were overwhelmed and laboring women would be seen according to their place in line instead of their stage in labor. When women were seen, they expressed dissatisfaction because of limited contact and negative interactions with nurse midwives.
Oftentimes, one nurse midwife would be attending to as many as 16 patients at a time. Logistically, that would mean many women were left unattended during their birth in the hospital. No friends or family were allowed to stay with mothers and mothers were left to labor and deliver alone.
The delays in responses to the mothers’ conditions led to increased risk of avoidable complications such as excessive bleeding and seizures. The nurse midwives, overworked and underpaid, let out frustrations at the mothers. Mothers have reported being told to “Shut your mouth! You’re not ready yet!” Young mothers felt ignored but they still felt dependent on medical expertise in case of emergencies.
During times of distress in the hospital, it is reported that women didn’t really turn to each other for community. It is as if they were missing the role of the nana, that provided social cohesion through natural cycles with comforting words.
However, since the British colonial public health policy statements vocalized a concern with the competence of the folk midwife, the nana was discredited and forgotten. Now it is almost impossible to find traces of her practices and knowledge in the few sources written about Jamaican midwifery. And nothing has been done to mend the cultural discrepancies in Jamaica’s history of childbirth.
Current Maternity System
To mend the catastrophe created by the economic decline, the Jamaican government sought financial assistance to improve the hospital maternity system.
In 2013 the Jamaican government signed a $3 billion agreement of support from the European Union for the development of PROMAC, Programme for the Reduction of Maternal and Child Mortality, which aims at reducing child mortality and improving maternal health. This collaboration has introduced improvements in hospital supplies and resources, new technology and free trainings.
Hospitals received 6 more ambulances, ultrasound equipment, and fully equipped tool bags for midwives. Trainings now include a free two year certified program for people under the age of 40 that are interested in becoming nurse midwives.
Interestingly, there is a separate mature entrance exam for people interested in practicing nurse midwifery over the age of 40 which seems like an antagonist sentiment against nanas and their traditional birth attendance practices.
The maternal mortality rate and infant mortality rate have decreased due to these interventions but it is important to note that this may be history repeating itself. The European Union is comprised of former colonizers: Britain, The Netherlands, and France. Their financial contributions can very well be another form of controlling Jamaica even after its independence in 1962.
The European Union’s intervention was able to lower the maternal and child mortality rate but they are continuing to push a medicalized, hospital centered understanding of birth in Jamaica.
According to the standards outlined by Davis-Floyd et al., this model of birth in Jamaica does not reach its potential for improving maternal health because of its failure to address its shortcomings, allegiance to professional practitioners, and ignorance and disrespect for cultural practices that maintain a social understanding of the significance of birth.
Assisting the Birthing Process
The most critical concern to be addressed in Jamaica is the unnecessary harm to mothers and children due to the lack of assistance during the birthing process. Since the hospitals are controlled by the Jamaican government, any dysfunction trickles down to health facilities and can affect motivation or funding to maintain basic obstetric care.
Despite several public outcries and the promise by authorities to overhaul the public Healthcare system, pockets of reports of disrespectful and abusive treatment remain in Jamaica.
It is necessary that new programs introduced to the maternity system in Jamaica address the abuse and implement preventive measures for hospital staffs’ negative attitudes. For example, increasing the number of nurse-midwives on call would decrease patient neglect and including higher wages for nurse midwives may affect their attitudes towards patients. Additionally, the allegiance to biomedical practitioners prevents folk midwives from being a resource to mothers.
Efforts should be made towards rewriting the policy that discredited folk midwifery practices and also towards creating more cooperative efforts between medical professionals and indigenous practitioners.
Developing this relationship has the potential to improve the cultural efficacy of medicine and medical consultation for mothers. When a midwife transports a client to a hospital, she has knowledge vital to the successful treatment of the mother.
Keys to effective systems of consultation during pregnancy would include being open to the knowledge the midwife might have inherited from disappearing folk midwifery practices. These ideas are speculative but could open avenues to crafting a more humanist model of birth in Jamaica.
Jamaica, the largest island in the Northern Caribbean, has a rich history of continuous British involvement and indigenous cultures contributing to the natural process of giving birth and providing care for mothers and children. Throughout history, the European financial inventors favor the push towards biomedical professionals, technology, and practices.
However, that system of thought has failed to see the value of respecting the community’s wise and experienced midwives, nanas. As a result, policy has disrespected the community’s elders and the knowledge that has sustained Jamaica’s population. Now it is almost impossible to find traces of her practices and knowledge in the few sources written about Jamaican midwifery.
Hospitals are becoming increasingly more dysfunctional in unstable economic times and inflicting harm to the mothers and negatively impacting their birthing experience. The maternity system in Jamaica follows a birthing model that isn’t serving women’s needs.
Since the continued involvement of Britain has failed to address the main shortcomings in maternal healthcare, there is a chance that more harm than good may come from PROMAC’s interventions in years to come.
