BOCHIL, Chiapas, Mexico -- "Una nina," the old woman said with a smile. A girl.
Known simply as Dona Mercedes, the midwife had made this diagnosis after pressing wrinkled hands down hard on the swollen brown belly of the woman sprawled beneath her. The examination table was a deflated mattress topped with rumpled blankets and mismatched sheets; the examination room was strewn with clothes, toiletries, dirt and an odd string of Christmas lights.
Maria Lopez Mendoza, the pregnant woman on the bed, nodded in agreement. A health worker in San Cristobal de las Casas, Lopez had been checked by ultrasound just a few weeks earlier. She already planned to name her baby Marisol.
While Lopez has access to both modern and alternative prenatal care and reproductive services, many women in this state -- where 70 percent of residents live in poverty -- have little to none.
That has contributed to an alarmingly high maternal mortality rate. In Chiapas, 61 women die per 100,000 live births, according to the United Nations Millennium Summit Goals, 11 more deaths than the Mexican national average and three times the maternal mortality rate in the U.S.
Among Mexico's 31 states, Chiapas' maternal mortality rate in 2012 trailed only Guerrero, another state in the impoverished south.
The numbers have drawn the attention of Mexico's government and a host of international non-governmental organizations like Marie Stopes International, which Lopez is a "promotora de salud" - a health promoter - and advocates for sexual health and reproductive rights.
All the organizations are committed to making childbirth safer, but they disagree over how best to do it. The government wants all births to be medically supervised, but NGOs say the problem needs both modern and traditional methods, including midwifery, since many villages are difficult to reach and few have medically trained clinicians.
A long road to care
Lopez's trip to see Dona Mercedes, for example, required a two-hour taxi ride through the jungle on a precariously curved road, often cloaked in fog, to reach Bochil - a city of fewer than 25,000 in the highlands northeast of San Cristobal.
The taxi was 60 pesos -- just under $5 -- each way. Most villagers are farmers making a subsistence living, meaning taxis are a luxury not often utilized, even for a woman in labor.
Even if they could get there, many indigenous people are wary of outside influences, let alone government-run hospitals and clinics staffed by doctors who often don't speak their languages or understand their culture and rituals.
Dr. Marcos Arana of CCESC-DDS, a health advocacy group in Chiapas, said the government policy may be well-intentioned but is woefully uninformed, particularly in regard to the poor and indigenous communities in largely rural Chiapas. Arana said that has led to overcrowded hospitals, low-quality care and a huge spike in cesarean sections.
Arana said the government has taken aim at traditional midwives, claiming they are not qualified to take care of pregnant women. "This has dismantled the liberty of health services in small communities," Arana said.
He called that policy wrong for Chiapas, where indigenous traditions can conflict with the 21st-century ideals of the government and mestizo upper classes. Arana says a more multicultural approach would "build links of trust" between doctors and traditional healers like midwives.
The government has voiced support in recent years for more professional midwife training to complement hospital births under a doctor's care. And Mexican officials signed on to Salud Mesoamerica 2015 (SM 2015), a multicountry, public-private partnership partially funded by the Bill and Melinda Gates Foundation. In Chiapas, it aims to reduce infant and mortality rates by improving access to quality health care by 2015 and promoting "midwife incentives."
Neither Lopez, her coworkers at Marie Stopes nor other NGOs that support midwives had heard of SM 2015. But some pointed to the work being done at CASA, Mexico's only government-accredited midwifery school, more than 1,000 kilometers north of Chiapas.
Nina Weber, a development coordinator with CASA, said it has graduated 79 professional midwives since opening in 1996, six of whom were from Chiapas. Even with training, however, Arana said professional midwives still face obstacles when seeking work in the health system back in Chiapas.
"You would need an army of professional midwives to change the situation," he said.
The old and the new
Professional midwives get formal medical training and are licensed to practice in clinics and hospitals while a traditional midwife -- a "partera" -- has long been regarded as a respected, sometimes divinely chosen, member of Mayan society, including among the Tzotzil and Tzeltal peoples of Chiapas.
OMIECH, an NGO that runs the Maya Medicine Museum in San Cristobal, said midwives are traditional healers who pass down wisdom of herbal remedies and safe childbirth over generations. Indeed, Dona Mercedes' mother was a midwife, although none of her 10 children plan to follow in her footsteps.
"They don't want to be, they're scared," Dona Mercedes said.
Traditional midwifery and health care is prioritized at K'inal Antzetik ("Land of Women" in Tzeltal), an NGO and women's cooperative on the outskirts of San Cristobal.
Claudia Vasquez Perez, a traditionally trained midwife who works at K'inal as a volunteer coordinator, said they grow medicinal plants on site and turn them into teas and tinctures in their "lab" - a collection of plastic beach pails and old pots on a shelf in K'inal's examination room.
Holding up a large plastic bag labeled "la cola de caballo," (horse's tail), Vasquez explained that the yellowed, brittle herbs inside cure urinary tract infections. Hands caked in dirt from a morning spent tilling the K'inal garden soil, she argued that such traditional remedies have worked for centuries, relying on the faith of the caregiver and the recipient.
"The plants listen to you," she said.
Though K'inal promotes traditional medicines, volunteers do learn a handful of modern procedures such as taking temperatures and giving injections. They host multiday sessions in indigenous communities for midwives and local women to learn this kind of hybrid health care.
Participants are also taught to spot warning signs that a pregnant woman's life or the life of her baby is in danger. At those times, K'inal uses proceeds from medicinal herb sales to help pay for transportation to a hospital. Vasquez sees that as indicative of K'inal's realistic approach to women's health.
"Cancer will not be cured by herbs," she said.
But some see more scientific intervention as necessary to reducing maternal deaths and improving sexual health and awareness in Chiapas. Increasingly, young indigenous women are advocating for sex education, using birth control and even receiving medical training to integrate modern health care into their communities.
Maria Luna and Susana Patricia Lopez, both 21, are nursing students in San Cristobal on scholarships from La FOMMA, a nonprofit that helps support indigenous people in professional pursuits.
Luna, a soft-spoken Tzeltal woman of tiny stature with striking features, said she enjoys learning the technical aspects of obstetrics, noting that traditional medicine and herbal remedies are not always enough.
Luna left her small community after primary school to go to high school in San Cristobal and then applied to nursing school. Her independence was not viewed favorably by her parents, farmers who would have preferred her to stick around, get married and have babies.
"I don't have communication with my father," she said, forlorn but resolute.
But Luna -- who works nights at a local hotel to help pay for her tuition -- hopes to one day return to her village, find a nursing job and focus on educating women about their rights to medical care and sexual health.
"Education in birth control and general health is the most important thing" in improving maternal health, Luna said.
Susana Lopez, the more demonstrative of the pair, said her studies span the scope of primary care, though she is specifically interested in prenatal care and assisting during labor and delivery. Like Luna, she would rather work in her Tzotzil community in the highlands outside San Cristobal than a hospital, which is "less personal."
When asked why she chose to become a nurse rather than a professionally trained midwife, Lopez said that, despite the license, "midwives are not valued as much." Plus, they earn far less money.
As a nurse, Lopez said she would have access to better equipment and resources than a traditional midwife, but could still have a personal relationship with patients.
Unlike Luna, Lopez said her parents are supportive and she goes home most weekends. Still, she said they were originally skeptical of her decision to pursue an education, which she said is typical of most people in her community. Acculturation, she said, is "a big process."
Despite a younger generation that's making gains in scientific training and awareness, there are still cultural barriers to sexual health in Chiapas. Mistrust of government-run hospitals and clinics lingers in indigenous communities.
Vasquez, the K'inal volunteer coordinator, said husbands may even forbid hospital visits because they are worried about how their wives will be treated or where they'll be touched. This machismo, she said, contributes to the high maternal death rate, because pregnant women are not getting needed medical intervention.
Vasquez and the nursing students also pointed to ingrained societal taboos about sex. Parents and teachers do not talk to children about sexual health and reproduction, leaving generations of women who do not know their options when it comes to pregnancy and, on a larger scale, their well-being.
So it has been left to NGOs to educate women about sexual health in a country that has long preferred to sweep such matters under the rug, they said.
NGOs like K'inal Antzetik and Marie Stopes say training and small-scale, volunteer sexual education networks are all they can do with the government that will not give such education in schools or provide enough contraceptives in clinics and hospitals, yet expects all births to take place under medical supervision.
In lieu of going to government-run hospitals, uninsured or otherwise distrustful women in Chiapas can receive birth control and gynecological exams at low costs at the impeccably clean and modern Marie Stopes clinic in San Cristobal.
Hovering over a table filled with an impressive mound of individual birth-control boxes, projects coordinator Geicel Yamileth Benitez Fuentes said they carry everything from daily contraceptive pills to intrauterine devices (IUDs) that can last five years. She said women often seek out private clinics like theirs over the government ones because of the more-personal care.
"Government clinics don't treat people with respect," she said.
Benitez said Marie Stopes also does a lot of work outside the well-manicured cobblestone streets of San Cristobal. In indigenous towns, what Benitez called "the communities," Marie Stopes health promoters explain how contraceptives work, demonstrate condom use and review the risks of sexually transmitted infections.
"There is a lot of unprotected sex because kids don't receive sex education," Benitez said. "There is not much awareness in the communities."
Marie Stopes has used its international funding and the community connections of midwives to build a network aimed at reducing unwanted pregnancies and maternal mortality.
Health promoters like Maria Lopez Mendoza sell contraceptives in communities around Chiapas to traditional midwives like Dona Mercedes, who then sell them to their own patients for a small profit.
Marie Stopes' goal, as stated in the stacks of brochures and framed pictures throughout the clinic, is "hijos para eleccion" -- children by choice -- something pregnant health promoter Maria Lopez Mendoza has fully embodied.
'They do it to serve the people'
At 43, Lopez said this is her last chance to have a baby. With the father out of the picture, Lopez is prepared to raise the child on her own -- single motherhood by choice.
Six months along, Lopez seemed as comfortable on the disheveled bed in Dona Mercedes' dilapidated house as she was in the Marie Stopes Clinic in San Cristobal. Despite the ease with which she straddled both worlds, she said she planned to deliver her baby girl in a hospital, where doctors can intervene quickly in case anything goes wrong.
She laughs and quickly dismisses praise that she is brave for going it alone, noting that many mothers in similar situations don't have the luxuries of a paying job or cash for a taxi ride to faraway clinics. In these instances, they have no choice but to rely on a local partera like Dona Mercedes.
Prior to her check-up, Lopez and Dona Mercedes had some business to transact: Lopez made the two-hour trip from San Cristobal to Bochil to deliver just three contraceptive kits the midwife had ordered for her patients.
Each kit cost 280 pesos, or about $20. Lopez explained that the midwife would mark up the kits by as little as 50 pesos so that her poorest patients could afford them, as opposed to similar kits sold at hospitals for as much as 2,000 pesos.
"That is the work of the partera. They earn almost nothing," Lopez said. "They do it to support the people. That is the way it is."