REPLAY: EBB 283 – How Colonialism, Environmental Instability, & Politics Impact Birth in Puerto Rico with EBB Instructors, Tania Silva Meléndez and Tamara Trinidad González, CPM

Rebecca Dekker:

Hi everyone and bienvenidos. On today’s podcast, we’re going to talk with Tania Silva Meléndez and Tamara Trinidad González, birth workers and Evidence Based Birth® instructors about giving birth and midwifery care in Puerto Rico.

Welcome to the Evidence Based Birth® podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi everyone and welcome to the Evidence Based Birth Podcast®. Today I‘m so excited to share with you a replay from a very important episode with Tania and Tamara. As a content note, this podcast episode does contain discussion of obstetric violence and colonialism. I also want to give you a head‘s up that if you listen all the way to the end, we will give you a current update on the situation in Puerto Rico that Partera Tamara was kind enough to send to us.

If you would like to read a transcript of this episode in Spanish, please visit the link in the show notes. Or you can watch the captions in Spanish on YouTube.

Si desea leer una transcripción de este episodio en español, visite el enlace en las notas del programa. O usted puede ver los subtítulos en español en YouTube.

And now I’d like to introduce our honored guests. Tania Silva Meléndez, pronouns she/her, is a certified birth, postpartum, and abortion doula serving families in Puerto Rico since 2009. She’s also a certified childbirth educator and breastfeeding/chestfeeding education and counselor.

Tania supports all kinds of families with evidence based information, empathy, and respect. She hosts support groups, teaches breastfeeding and chestfeeding classes and childbirth classes to expectant parents and birth professionals both in her private practice and in the organization she works with. She is general coordinator of the team of Caderamen, a nonprofit community-based organization that works towards reducing inequalities in reproductive care, and she also supports Alimentación Segura Infantil, a community-based organization born after the impacts of Hurricanes Irma and Maria in 2017 to support breastfeeding and chestfeeding families in their lactation journeys, help them relactate when needed. Tania is also a human rights activist and advocate in her community and part of the Observatorio de Violencia Obstétrica in Puerto Rico and Las Mingas de Aborto, an abortion doula collective that offers free support in Puerto Rico.

Tamara Trinidad González, pronouns she/her, is a community partera/midwife, perinatal educator and herbalist born and raised in Puerto Rico. Tamara is a mother of two children who were born at home with midwives and has been actively involved in birth work for 10 years. She holds a master of science and midwifery with foundations in botanical medicine from Bastyr University and is a certified professional midwife. Her midwifery and herbal practice is called Semilla Creciente, Midwifery & Herbalism.

Tamara is currently the president of the Puerto Rico Midwifery Association and part of the board of the National Association for Certified Professional Midwives and she’s very committed to educational equity and political aspects of the midwifery profession. As a professional in her community, Tamara is passionate about building connections and collaborations between midwives and other health professionals in Puerto Rico with the hope that with these better relationships and communication can build smooth transfers when needed, with the goal of facilitating the best care possible for families giving birth in Puerto Rico. Both Tania and Tamara became Evidence Based Birth® Instructors in 2021. I’m so thrilled that both Tania and Tamara are here. Welcome and bienvenidas to the Evidence Based Birth® podcast.

Tania Silva Meléndez:

Thank you. We’re also very thrilled.

Tamara Trinidad González:

Yes, very honored to be here finally in this space. Thank you.

Rebecca Dekker:

Yeah, and I so enjoyed meeting you both in Puerto Rico this January. It was the highlight of my year so far, and I am just so excited that our listeners get a chance to hear from you. Can you talk with our listeners about what inspired each of you to go into birth work in the first place?

Tania Silva Meléndez:

Okay, I’ll start. This is Tania. When my husband and I realized that we were ready to have a baby and we wanted to quit birth control, we started researching a little bit about birth and we started getting educated. So I crossed with the documentary, The Business of Being Born, and I confirmed what I suspected that I want. I didn’t want to give birth in a hospital, so I started searching for midwives in Puerto Rico. And I remembered a friend of my brother that gave birth at home, so I called her and she gave me information about midwives in Puerto Rico.

That was around November, December, and on December, there was photographic exposition of home birth photography that coincided with the inauguration of Centro Mam, which is a community-based organization that supports reproductive process of woman, mostly birth and with midwives and doulas and all that stuff. And that December, there was going to be a doula certification. So I said, “Hmm, I’m going to do this for myself and maybe to help my friend.” And in the past I felt the calling. I just recently finished two master’s degrees in business and international business. Has nothing to do with birth, but that’s how I entered this world. Then I became a childbirth educator, and then I became a mother and a breastfeeding/chestfeeding educator afterwards.

Rebecca Dekker:

Yeah. And how many years have you been in birth work then, Tania?

Tania Silva Meléndez:

I certificated in 2009, so it’s been almost 13 years, 14 years.

Rebecca Dekker:

Wow. 13 or 14 years, that’s amazing. And Tamara, how about you? How did you get into midwifery and becoming a partera?

Tamara Trinidad González:

Well, right before my first pregnancy around 2010, 2011, I was already trying to see what I wanted to do for grad school. I had a bachelor’s degree in biology and I was working in conservation, environmental conservation and education. But I was able to go to Honduras on a journey and I was able to see medical professionals. I didn’t know any skills, taking vitals or anything, but I was able to support the team and coordinating volunteers.

Right after that trip, I started thinking, “Huh, I think I really want to try to consider pursuing something related to health.” I wasn’t sure if it was going to medical school, which a lot of my classmates in the bachelor’s degree were doing, or public health. So I think everything is just connected because midwifery, it’s public health. But then I think became pregnant and then the journey started of me looking for options and realizing that there were not a lot of options and that finding a midwife was kind of a challenge. Back then, there were only three direct-entry midwives [on the island], but I was happy that I connected with one of them because I actually thought it was an extinct profession. And my father was born at home with midwives, so it wasn’t too far away from me in terms of history and connecting with those realities and those options.

But then if I wanted to do that, I needed an OB that was willing to respect my option of midwifery care in a parallel way and respect my option of doing a home birth. So for that, I had to travel two hours back and forth each way for each appointment because I didn’t live close to that doctor. And then the long story short, after I finally was able to have my respected process at home during the births, in the midst of all the oxytocin high, I was also kind of in shock and all the images of the process and my midwife right there confirming health, being so respectful, so calm, and letting me be, I remember that I just felt a message right in my heart saying, “This should be accessible for everyone. It shouldn’t be so hard.”

I was determined, I had a good work, I had education that allowed me to do research, but it wasn’t accessible at all. I think that seed kept growing, because at first I was like, “I’m just in an oxytocin high, of course.” But then like a year after, I saw a doula course and I registered on it, and I did it and became a doula. Then two years after that, I saw the perinatal educator course, but midwifery calling was always there. And I started to getting to know all the midwifery community and seeing it grow, seeing more students that were already coursing, graduating and beginning their practices. And five years after I gave birth to my first child is when I was able to start midwifery school and yes, here I am around 12 years later, a midwife in Puerto Rico and there’s even more midwives, and it’s very exciting to see the community grow and the options grow.

Rebecca Dekker:

So when you had your first baby at home, you said there were three midwives doing home births in Puerto Rico?

Tamara Trinidad González:

There were three direct-entry midwives. There were also some nurse midwives as well that were also doing home birth, but I didn’t know that in that moment.

Rebecca Dekker:

So about a handful of midwives and nurse midwives. And do you know how many there are now on the island?

Tamara Trinidad González:

Yes. There’s now 16 direct-entry midwives. 14 of us are CPMs, there’s 12 students in different schools for direct-entry midwifery programs, and there’s about 13 nurse midwives.

Rebecca Dekker:

Wow.

Tamara Trinidad González:

I’m not sure how many of them are currently in practice, but there’s also many of them, like probably half of them are in practice.

Rebecca Dekker:

So you were living through hopefully a rejuvenation of midwifery in Puerto Rico. You’re seeing it happen.

Tamara Trinidad González:

Yeah. Yeah. We’re seeing it all 3D.

Rebecca Dekker:

I know that’s encouraging news, but I also have learned from you that the birth environment for families and birth workers can be very difficult and challenging. Can you talk to us about birth in Puerto Rico? What is the birth rate? How easy is it to access care from an obstetrician or midwife, and what’s the culture of birth there in the hospitals?

Tania Silva Meléndez:

Okay, so this is Tania again. This is like a summary of the birth scenery in Puerto Rico. When I started doula-ing, around 42,000 babies were born each year. Today, there’s been a significant decrease, around 19,000 babies are being born every year.

Rebecca Dekker:

So your birth rate has been decreased by half?

Tania Silva Meléndez:

Yes, yes. And it has to do with migration because of the economic crisis in Puerto Rico and all the disasters, the hurricanes, the earthquakes, the government, the imposition of the Junta de Control Fiscal, I think we’re going to talk about that, the colonial stuff in Puerto Rico, and also because of Zika. When Zika was happening, the Zika virus.

Rebecca Dekker:

Oh, the Zika virus, yes.

Tania Silva Meléndez:

There was a big campaign on birth control. So the government was offering free birth control, long-term birth control with intrauterine devices being inserted for free for women. So that also affected natality in Puerto Rico. Besides the natality being dropped in terms of outcomes, we have a very high Cesarean rate, one of the highest in the world and in the United States, and I’m talking about the United States context because we’re a colony of the United States. So in 2021, we had 49.6% of Cesarean rate.

Rebecca Dekker:

So one half?

Tania Silva Meléndez:

Uh-huh. It’s been like that since I started doing birth work. Around the 40-somethings, 46, 47, 46, 48, 49. There’s a very low rate of VBAC, around 1%. There’s a very high prematurity rate and low birth weight both in 2021 were 12%. One of the highest in the United States also. So that’s the scenery here.

In terms of obstetrician, of course, also because of the crisis, there’s been a lot of fleeing of medical doctors in all areas of health, but also obstetricians. So we can say that maybe around 100 obstetricians take care of those 20,000 births. It’s an access problem. When we talk about obstetric violence, we know that it’s not only personal, it’s violent, but it’s a systemic problem really, because how can 100 doctors take care of 19,000 births a year? You know?

So yeah, in terms of how open the system is to these type of birth workers, midwives, and doulas, in terms, I’m going to talk about doulas and maybe Tamara can talk about the midwives. Since we are growing like midwives, when I started, there wasn’t as many doulas, and every year, maybe 200 – 300 women or people get certified as doulas. So we are more now, and since we are more, doctors and hospitals are getting more used to work with us. Some are super open, are super cool, and understand the benefit of having us in their team, but some are still hesitant about the work that we do. They don’t even understand properly what a doula does. Sometimes I come to the hospital with a client, and they ask me how dilated she is… “I’m sorry doctor, I don’t do clinical stuff.” I can tell by her face, her contractions, her breathing, she might be in a labor around this, around that, but they don’t even understand our scope of practice.

But yeah, they’re more open now, and the restrictions on the pandemic have taken us back again a couple of years back in terms of access and birth rights violations. But yeah, we hope that changes.

Tamara Trinidad González:

I agree that seeing an increase in doula and midwives in the past decade sounds very encouraging and I’m sure it has made a huge difference in a lot of families, but there’s so much more that needs to be done and that needs to change, especially in the mentality of those that hold power. Because there’s a lot of power dynamics that happen in the birth scenario, not only in the birth scenario, from the moment they find out, any woman or pregnant person when they found out they have a positive pregnancy test and they’re trying to explore what are their options moving forward.

Midwifery and doula is not something that they immediately find out if they don’t know about it. Some people find out very late and they are feeling discouraged of like, “Why didn’t I know about this earlier on?” So we’re doing educating since the beginning is a very important piece of the puzzle right there.

Midwifery care here, it’s just very different to how it works in other states and territories because one of the big differences is that the Department of Health still doesn’t consider us healthcare workers because we’re still not licensed here. We still don’t have a regulation. Well, we don’t have it right now. There used to be one, and then midwifery language was erased from that regulation. So it’s been then like that for about, well…

Tania Silva Meléndez:

Since the ’40s.

Tamara Trinidad González:

Since the ’40s, which is kind of around the corner, the 100th anniversary, right?

Tania Silva Meléndez:

Moved birth from the home and the midwife care to the hospital. The midwife language in the Health Department of Puerto Rico was erased as midwives were erased from the-

Rebecca Dekker:

They literally tried to erase midwives.

Tamara Trinidad González:

Yeah, but it hasn’t stopped. The profession has continued. How it works is that in order for people to access their labs and their ultrasounds, they also need medical care. But ideally, it could be a parallel work where the midwife and the doctor can discuss and communicate between each other. And that’s how some of the midwives have been able to do it. I have been able to do that with some doctors, but again, it’s only a handful of doctors that are open to this. There are some solutions, that we’re going to propose later on, of how to change this.

In Washington state, where I studied or I grew up as a midwife, as a baby midwife, what I saw was very different because we were the primary care provider. As soon as the person found out they were pregnant, they could automatically choose an OB or a midwife. And then if they chose a midwife, they still had three options: a midwife in the hospital, a midwife in a birth center, or a midwife at home. So there’s a huge difference there. We are definitely needing to move forward because there is not a lot of understanding and a lot of the aggressive comments towards the family that choose midwifery care and home births come from providers that they don’t have all the information. So there’s a lot of misconceptions, especially if a misconception is held by the older OBs and they’re teaching younger OBs and students, the information may be passed in ways that are not accurate and then that just gives a lot of space to bias and education can absolutely change that, and that’s where we’re going to move to.

Rebecca Dekker:

So in order to have midwifery care, you have to have an OB who agrees to be providing the backup or the parallel care, to order any lab tests, to help you get an ultrasound, or if you need any medications during pregnancy or labor. So that kind of limits the midwives and the parents because there’s very few doctors who will agree to do that. And then I imagine if a client needs to transfer to the hospital, which happens, will always be happening at some point, I imagine you face a difficult circumstance when you bring them to the hospital. Is that correct?

Tamara Trinidad González:

Absolutely. Especially because even if we have a good communication with the doctor, the doctor is also employed by the hospital, so there’s also so much they can do. They’re also oppressed by the system and the dynamics that are happening there. So even if a doctor knows, “Oh, I am transferring this client because she says she’s tried all of the things, all of the comfort measures, and she’s very ready for pain medication, or she wants to try something else.” Even if it’s not an emergency and it’s just a stable mom that wants other option? If I tell the doctor, and the doctor knows, but I arrive there and the doctor is not there yet, then how do I access the other personnel that are going to receive us if they don’t even answer the phone? It’s like beginning from zero.

And then the charting. Midwives here, we chart in the same language, the same acronyms are used for charting the same SOAP notes and even longer SOAP notes. And we have electronic charting, some do paper charting, depending. But the thing is that… that is a very powerful tool that could be used for continuity of care and communication, because there’s no space for thinking that we’re transferring an unstable mom, or if we are transferring someone that needs maybe an emergency process, let’s just avoid the questions of how many pregnancies you’ve had in the past if what we’re going for is like a continuous monitoring or something else.

But it’s a tool that’s many times it’s just not accepted. They don’t want to read it. I think communication is just very powerful and not being afraid. I have had sort of good experiences just advocating for families and standing strong and speaking my truth. “No, this is my training, this is the charting, what email can I send it to?” And then little by little, I see the layers of resistance opening up, but it takes time and it really depends who’s receiving us. And it still takes time away from the family. It shouldn’t be like a battle and a struggle, and it is a huge challenge that ultimately families are the ones that are affected, right?

Rebecca Dekker:

Right. And they’re the ones trying to escape a system that gives them a 50% chance of having a Cesarean and also a high likelihood of experiencing potential abuse during the birthing process. And then when they do need that extra medical help, these are the kinds of barriers they face.

Can you talk a little bit about what impact colonization continues to have on families and birth workers in Puerto Rico?

Tania Silva Meléndez:

Yes. Well, I would like to explain a little bit about our status, because not every person know where we stand. Puerto Rico, since 1917, well, we became a colony of the United States in 1898 after the Spain-American War. We were prized from Spain to the United States, and in 1917, they gave Puerto Ricans U.S. citizenships. Every baby born in Puerto Rico became a U.S. citizen at the same time that our men were sent to the World War I for the United States Army.

Colonization has limited the autonomy of our nation. Everything that we consume, about 85% that we consume in Puerto Rico is imported from or through the United States. Sometimes if it’s an international product or service, paying double taxes because of this loss, and that’s not even talking about the colonized mind. What Tamara was talking earlier about the power struggle and this mentality that you don’t question authority, you have to be subjected to whatever is imposed… is a little bit intrinsic in our ways of being and acting and accepting and doing. So that’s a little bit on what we are. We are a commonwealth of the United States, but what we are is a colony in the 21st century.

Tamara Trinidad González:

We are a democracy with a lot of dictatorship.

Tania Silva Meléndez:

Exactly. As early as 2016, the U.S. Congress imposed a fiscal board to Puerto Rico. It’s a board of seven mostly white people that are not necessarily Puerto Ricans. They are not Puerto Ricans. I think maybe there’s one Puerto Rican now. They were appointed to, it’s by a law that it’s called the Puerto Rico Oversight Management and Economic Stability Act.

Tamara Trinidad González:

PROMESA.

Tania Silva Meléndez:

PROMESA in Spanish. So it was established in 2016 as a financial oversight board in order to restructure our debt, and expedite procedures for approving critical infrastructure projects in order to combat the Puerto Rico and government debt crisis. But that imposition, first of all, the people that is governing us wasn’t elected by Puerto Ricans, was imposed by the U.S. Congress, and it’s going to be governing us until 2026. We still have our governor, we still have our House of Representatives, the Senate, but no matter what they say, if the Junta says “No, this is not happening,” they overrule it.

This austerity plan has deeply cut into Puerto Rico’s public service budget, including cuts to healthcare, pensions and education in order to repay credit. So that’s super colonial and we are seeing the impacts of it. This morning, I was telling Tamara, this morning the cover of the main newspaper in Puerto Rico, El Nuevo Día, was exposing that there’s a crisis with NICUs in Puerto Rico. Neonatal intensive care unit. So in the last year, about five NICUs have closed in Puerto Rico. The health crisis is already here. We have the experience that when our clients give birth, they cannot find a pediatrician to see their babies as soon as they should be seen. Colonialism is really affecting us in all aspects of our lives.

Rebecca Dekker:

Right, education, healthcare work, what prices you pay for things, what control you have. And also it’s worth mentioning that it’s supposedly democracy, but you have no representation in the U.S. Congress. So really no say-

Tania Silva Meléndez:

And we cannot vote for the president, either.

Rebecca Dekker:

Right. You mentioned the effect on NICUs, and I know when we talked together in person, you talked about gentrification. Can you mention that a little bit?

Tania Silva Meléndez:

Yes. A couple of years ago, there was a law that was created, a couple of laws created in order to incentivize American investment in Puerto Rico where they offered investors to come to Puerto Rico, invest, and they didn’t have to pay any taxes on any capital gain. So as you may imagine, a lot of rich investors come to Puerto Rico, buy land, buy property, establish AirBnBs, and Puerto Ricans have no access. There’s a problem in terms of home access. I have a friend that she, her husband, and her three kids are living in a studio because they cannot find an affordable house.

And it’s a problem that is happening all over the island. On the coasts where the beaches are, in the centers of the island, everywhere. So gentrification is a major problem. I was reading yesterday about medical tourism and how these companies are establishing like a medical concierge service where rich person can pay a membership of let’s say $5,000 a year and this company will book you appointments without waiting. So me, that I’m a Puerto Rican with no economic access if I need some, let’s say, I don’t know, dermatologic care, I have to wait five, six months for an appointment. And that’s in all services. That happens with us, especially for specialist.

Tamara Trinidad González:

Yeah. Even dental work.

Tania Silva Meléndez:

Dental work, whatever. Whatever.

Tamara Trinidad González:

And it’s also an environmental crisis. It amplifies the health issue because one of our battles, environmental battles, is the access to our beaches, which is the access needs to be public according to the laws, but for the rich people and the rich investors, even though the Department of Natural Resources are giving out permits, because they can pay more for the permits and they’re able to build in the-

Tania Silva Meléndez:

fences and…

Tamara Trinidad González:

And even in the maritime zone, prohibiting the access to the locals and just creating other problems as well. There is many ways that colonialism is affecting us. And it’s just a chain, a chain reaction that we just keep seeing it unfold in our eyes because even if we’re involved in birth work, we’re also aware of everything else. Because again, birth work is public health and it’s also a lot of political work as well.

Rebecca Dekker:

And you’re also trying to live and raise your families.

Tania Silva Meléndez:

Yeah, exactly. The crisis.

Tamara Trinidad González:

The day in day.

Tania Silva Meléndez:

The struggles.

Tamara Trinidad González:

Yes. It’s like, and there’s a lot going on and it feels, we can feel the heaviness. And really, I think it hurts us a lot when we see how families are affected by all of it. We feel frustration when we see a family that finally went through all the courses and education, but at the end of the day, weren’t able to speak up at the hospital. Because all the years of colonialism have impacted them in such a way that some are, they just have so many intersections that have oppressed them that it’s just very hard. Being able to go in the hospitals with them as a second companion, it’s very important because even the pandemic was used as an excuse to take this right away from the families.

Tania Silva Meléndez:

Still is. Everything is open, everything is-

Rebecca Dekker:

Right. Nobody’s wearing masks, yeah. It’s open. Except they’re still limiting support in labor and delivery.

And I also want to say, I was really impacted by some videos from a journalist in Puerto Rico named Bianca Graulau.

Tania Silva Meléndez:

Graulau, uh-huh.

Rebecca Dekker:

Yeah. Some amazing videos about gentrification and just really on the ground reporting that’s incredible. So I encourage people to check out her work and we’ll link to that in the show notes.

Tania Silva Meléndez:

I was going to say that I think that one of the videos she did was about what is happening in Hawaii, and that’s where we’re going. That’s where Puerto Rico is going. People cannot afford homes. People are living in tents. It’s terrible. It’s terrible.

Rebecca Dekker:

What are some solutions you’ve tried to implement, or the birth community has tried to implement that seem to be helping families?

Tamara Trinidad González:

Evidence Based Birth®’s course!

Tania Silva Meléndez:

That’s one. Unfortunately, we cannot expect the government, nor the health department, nor the authorities that are obliged to take these matters into their hands. We cannot wait for them. It’s been, in my experience, I’ve been doing this work for 13, 14 years, and it’s so slow the changes, and so when something starts to change, then the pandemic, everything goes backward. I think that the only hope right now that I can really trust is community work. And it’s what has made a difference to some families.

I am a general coordinator of a nonprofit organization that is called Caderamen, and it has a program, a service program that is called SePARE, which offer education and doula services, midwifery services and naturopathic medicine services, social workers, mental health. We’ve seen in comparison to the numbers that we were mentioning, outcomes in Puerto Rico, we see how these support and interdisciplinary services for families really make a difference in the health outcomes and in the experience of this family. I would say that more work from the ground is what’s needed. We need to unite and seeing how from the community to the community we can support the families because it seems it’s not a priority of our government.

Tamara Trinidad González:

This is Tamara here. I wanted to add to that. Absolutely community work, it’s so way to go. And the force in which the community is putting the trust in because they are feeling respected, they’re feeling that they are being heard and they’re learning.

Social media and that boom is also a great tool that people from the younger generations, maybe they won’t be reading a very long article, but educational material that’s very dynamic, they are very drawn to that and it’s easier to see themselves and see, “Oh, these families from Puerto Rico are accessing this type of health.” Either home births or either they could even see images of hospital births where they’re able to move freely and they have support and there’s other things going on. So we’re very visual, so that helps as well.

And another thing that has been in conversation fairly recently is joining forces from different organizations and professionals and putting the situation in the center, the problem at the center to see how we can just find solutions from all the different resources and perspectives. Moving towards integration or some sort of coalition, just help us be stronger in the search of solutions, could continue making a huge difference.

All the midwives are just very clear that we’re ready to create a Puerto Rico license of midwifery, and we’re shaping up to how that would look. It can focus on the right of midwives to work in our scope of practice and how we have been trained and how we are valued in other parts of the world, but also it needs to be respecting the rights of the family to choose.

Rebecca Dekker:

Right.

Tania Silva Meléndez:

Another thing is that old obstetricians, their mindsets are difficult to change. So when we were talking to you on January here in Puerto Rico, we see that part of the solution, it’s working with younger generations, with the doctors that are being formed right now so that our hope, people that really want to make a difference in births in Puerto Rico.

Rebecca Dekker:

So groundwork from the community and growing the number of doulas and midwives and then finding unity are solutions you’re working on. And you mentioned to me when we met in person that you saw some recent legislative success. I know you have doubts about the government, but…tell our listeners.

Tania Silva Meléndez:

Okay, yes. First, it’s important that the Supreme Court of Puerto Rico made a ruling on a case of obstetric violence where a baby died [Flores v. Ryder Hospital]. In a summary, this doctor induced a mother with 36 weeks because he was going on vacation on her due date. The baby, of course, was born premature with a lot of complications, and 12 days later she died. So the family sued, the Supreme Court ruled that both the doctor and the hospital were responsible of the death of the baby. It’s the first time that the Supreme Court or any legal authority talked about obstetric violence and put a name on it.

In Latin America, some other countries have already legislation about obstetric violence. Here in Puerto Rico there’s a Senate bill, 454, that was proposed in June 2021. The Senate approved it, but still on the House to be approved. So we’ll see what happens with that. It’s important that this kind of behavior is named from the government, is named and something is proposed in order to deal with this gender violence issue.

Tamara Trinidad González:

Okay. Tamara here. Another legislative success is that in February 2021, around that date, a little bit earlier, a Senate bill was proposed to declare May 5th of every year, which is celebrated in every part of the world as the International Day of the Midwife, so what it was proposed is to declare a law in Puerto Rico that everyone, every sphere in the government, including the Department of Education and the Department of Health and everyone in the community, needs to know about Midwifery Day. So as recent as January of this year, and I think it was like a few days after before you arrived, it was finally declared a law. So it kind of went through all the steps in the government to finally become a law.

And although it’s been known for decades by the World Health Organization and the United Nations, it’s just very important that it’s now a law here and we believe that this will just open space to continue educating communities. And we hope that this law is just a step forward and a link so that midwifery care is finally recognized in Puerto Rico and reincorporated into the health services. And to celebrate this year, we are already planning an activity in a public plaza in Rio Grande, which is one of our municipalities. And that major just offered the plaza for free and it’s offering a lot of support so that we can just receive all the public and just talk about midwifery history and have artisans and have music and just make a public pueblo party.

Tania Silva Meléndez:

Celebration, yes.

Tamara Trinidad González:

A celebration and just continue raising awareness.

Rebecca Dekker:

And that was what I was thinking of… Obviously the obstetric violence ruling is very important, like you said.

Tania Silva Meléndez:

Yeah, because maybe hospitals will be more aware of they really have to do something about it. It’s not only the doctor’s fault. You have to have protocols, you have to supervise how things are work, that you’re following guidelines, et cetera, et cetera.

Rebecca Dekker:

Yeah, and the fact that they named obstetric violence and talked about it, and then in a similar time span, also naming midwives as a solution and requiring education basically to honor midwives is an important step towards hopefully moving forward. And I know you both are looking towards and working towards future legislation too, so that the midwives can practice with that.

I know it’s a difficult subject because in some places, midwives don’t necessarily want regulation, but if you’re also not recognized as a legitimate provider, it makes it very hard for you to get resources, access, respect.

Tania Silva Meléndez:

And it makes it harder for families too, because not everyone can afford a home birth.

Rebecca Dekker:

Right. If you could be recognized as a healthcare provider than there would be other ways for them to pay for your services as well. Yeah.

What other goals do you have for the future or any projects coming up?

Tamara Trinidad González:

I would love this year that we can just go into hospitals and into universities and just talk to professionals to people who are already professionals in the birth setting and to professionals that are in just developing, the ones that are in uterus. That when you mean, yes.

Rebecca Dekker:

[Laughs] The baby professionals or healthcare workers.

Tamara Trinidad González:

Yes.

Rebecca Dekker:

Yeah. So what were your plans? You talked about that in person. So what are you planning this year for that?

Tamara Trinidad González:

So we have reached out to people we know, other professionals we know that are either professors in universities. There’s two professionals, one is a family doctor and the other one is a nurse. She’s a nurse midwife, but she teaches specifically to general nursing students at a university. So they’re knocking on their doors because they also have the people they need to ask for that to happen.

But absolutely finding out ways, and I was in Colombia last week and talking to traditional midwives and how they collaborate so beautifully with female OBs and the perinatal mental health professionals, and they created a curriculum that was presented to a university for continuing education. And I just fell in love with that idea. I just see it completely possible, and it may be a way of making it more structured and also incentivized further training.

Rebecca Dekker:

Tania, what about you? What projects do you have in mind this year?

Tania Silva Meléndez:

We were talking about this, about training professionals last February at Caderamen Health Birth Summit and here in Puerto Rico. And some of the speakers were professors from medical students and obstetric residency. So this doctor, after we were in the same panel and after the presentation, she came to me and at least she told me that she’s very interested in working together. So that’s another entering path in order to access the medical school of the University of Puerto Rico, which is one of the most important medical schools in Puerto Rico. And we’re hoping that we can arrange something with her so that we can get to the students and also to them. So that in terms of education and doing something inside the system.

Personally, I guess, well, keep doing the work that we’re doing and prevent burnout because this is a very consuming work, the one that we do.

Tamara Trinidad González:

I wanted to add to that. Thank you for mentioning that. That’s just very important while we continue feeling the stress in our body. But I wanted to add, in part of educating, I remember when I was a midwifery student, one of the thesis projects that I fell in love with came from a midwifery student that she used to be an EMT before becoming a midwife when she was in that same state, in that same community where the university was. So it was very amazing to see how she was, she just had an amazing relationship with EMTs. So she was able to put up a curriculum because she was able to talk to the EMTs and tell them and ask them, “So when midwives call you for a transfer, what questions do you have?” The questions that they had was like, “Why do they ask us to put the mother in a certain position instead of this one? How does that affect what we know about resuscitation on newborn and giving those first steps is this, but how do you guys do it?”

With all that conversation, a beautiful curriculum and a very powerful one was able to put up together. So after that, they were able to go to every EMT unit and just teach them about what happens when a midwife calls you. In a birth center or in a home birth, what do we need? And that was very powerful because that was implemented a few years before I was finishing my program and what I saw, and for midwives, it was like, oh, we’re seeing the change. But I was completely impressed by this, that if we called 911 and EMTs arrived, it was a very humble moment of what do you need? It was the specific questions so that it didn’t become a battle. It was like, oh, no, they wanted to help and they wanted to do exactly what we needed so that there wasn’t any time lost in the moment.

So here, we need to do a lot of work because when we need a transfer for different reasons, simple things like what is the oxygen level that needs to be put becomes a fight, becomes a disagreement. And that is time-sensitive. That is a matter of life. Or other skills that need to be performed. So I think that putting together a curriculum that also can just be brought up together and help EMTs and see them as part of the team and honor their skills, but help them understand our perspectives and that we can understand their perspectives and their struggles as well, could be very powerful.

Rebecca Dekker:

I love how both of you have a passion for bringing people together. It’s one thing I’ve seen, you work together, you hold each other up and support one another, and you bring other birth workers and you have a passion for bringing students and EMTs and families and everybody working towards a common goal. So it’s very beautiful.

Tania Silva Meléndez:

Thank you.

Tamara Trinidad González:

There’s no other way.

Rebecca Dekker:

So how can people support and follow your work for our listeners who are impacted by your conversation?

Tania Silva Meléndez:

Well, I wanted to invite listeners to check out SePARE, or SePARE, we are in the different Facebook, Twitter, and Instagram. SePARE, you can check us out and follow our work from the organization that I work with, because even though I still have my private clients, the organization takes most of my time, so I am mostly devoted to that. You can also follow the Asociación de Parteras of Puerto Rico (@asociaciondeparteraspr). You want to tell more, Tamara?

Tamara Trinidad González:

Yeah. We’re going to send these links so that they’re easier to link on. But yeah, the Midwifery Association of Puerto Rico, although I also have my private practice, this currently the president of the association, and it is a space that we’re organizing to amplify the voices and the rights of the midwives and the families. We’re going to be putting up a lot of updates in the next few months of how to support midwifery work and towards advancing the profession.

This also includes that we need a lot of fundraising because there’s going to be a lot of services that we’re going to need to hire in order to do the work that needs to be done. So I would say just keep checking the pages so that you can find all the updates and you could also email us at appr2021@gmail.com, English or Spanish.

Rebecca Dekker:

And we’ll make sure to have all the links easy to click on, everything you send us that, that you want us to share. Tania and Tamara, thank you so much for coming on the podcast. Thank you for everything that you’re doing in Puerto Rico, and we honor and appreciate you both.

Tania Silva Meléndez:

Thank you.

Tamara Trinidad González:

Thank you so much for all the work you’ve also been doing, because you’ve been paving a way for everyone in every part of the world, and that is very crucial and needed.

Rebecca Dekker:

We’re doing it together.

Tania Silva Meléndez:

Yes, absolutely.

Rebecca Dekker:

Thank you everyone so much for listening to this very important episode! At the time this replay is airing, Partera Tamara sent several important updates for you to know about regarding hospital closures, declining birth rates, and midwives in Puerto Rico. So, here are the updates she sent to us:

About Hospital Closures and Labor & Delivery Units, Tamara writes that

Puerto Rico has experienced a reduction in healthcare facilities, particularly in rural areas, leading to the closure of several hospitals and labor and delivery units. This trend has worsened access issues for expectant mothers and birthing people, especially in underserved regions, and underscores the need for alternative birthing options and increased support for midwifery services.

She also sent us new info about Declining Birth Rates and writes that

Puerto Rico’s birth rate reached a historic low in 2023, with only 17,772 births recorded—the lowest since records began in 1888. Factors contributing to this decline include economic instability, emigration (meaning immigration out of Puerto Rico), and limited support for working parents. Experts warn that without intervention, the island faces demographic challenges, including an aging population and potential workforce shortages.

Finally, Tamara writes to us about Puerto Rican Midwifery and the Midwives’ Association

In response to healthcare access challenges, she writes, midwives have become increasingly vital in providing maternal care. In the Asociación de Parteras de Puerto Rico we have continued working and growing, with more midwives and midwifery students joining the profession. While the association was working hard in 2023 to create and present a bill to regulate midwifery, the current political environment is not optimal. For now, the focus is on educational campaigns and uniting voices from supporters, including other health professionals and families who use midwifery services, to advocate effectively when the opportunity for legislation arises.

In this same line, a midwifery supporter has just started a birth collective for Puerto Rico (

Since 2023, two practices in the community have evolved to offering families an alternative to traditional hospital births, similar to birth centers. The goal from the Asociacion is to eventually have regulations that allow and facilitate more free-standing birth centers in Puerto Rico, honoring the autonomy and scope of practice of midwives under a locally recognized license.

Midwives as Essential Community and Crisis Responders

Midwives are also playing a crucial role in supporting families with non-regulatory migration status, ensuring access to care in the midst of ongoing crises. Furthermore, midwives continue to serve as essential community responders for disaster and hurricane preparedness, providing education, guidance, and support before, during, and after extreme weather events.

Also, if much of this info was new to you, I recommend checking out a book or two from your library about the history of Puerto Rico. Two books that I’ve read and I recommend include “How to Hide an Empire” by Daniel Immerwahr, and “Puerto Rico, what everyone needs to know” by Jorge Duany.

Thanks again for listening, and I’ll see you next week. Bye!