Throughout this article gendered language, including female pronouns and the words “women” and “mothers,” is used to describe birthing people. This is in accordance with the way the advocates, interviewees, midwives and other professionals involved in the project identified themselves and their clients. We recognize that birthing is not exclusive to women and female identified people; transgender and non-conforming people may also get pregnant and give birth. We hope that the information in this article can still be useful to people of all gender identities, and acknowledge the limitations of the language used.
Two hours east of Port of Spain, Trinidad, down a winding, narrow road dotted with fallen mangos, a sign welcomes visitors to Brasso Seco. This small rainforest settlement is humming with birds and insects, the canopy is crowded with leaves, and vines hug the trunks of trees and hang from high branches.
Up the hill from the village health center, Francisca “Ma” Estrado sits in her oversized armchair in the home that she shares with her granddaughter and son. Born in 1916, Ma is 104 years old and has outlived six of her ten children. Visitors lean in close and speak loudly into her ear. When asked about her career she says,
“I wasn’t a real midwife but I used to help when any woman got pain and they didn’t have nobody to help them. But the nurse and the corporal they came to tell me that they were going to make me a kind of midwife to help all the poor women. Here didn’t have doctor, here didn’t have nurse, here didn’t have nothing. I didn’t used to take money from them.”
After practicing midwifery between the 1940s and 1970s, Ma is one of the few remaining midwives who served communities before natal care moved to the state’s medical system in the late 20th century. Her experience reflects an earlier time in Trinidad and Tobago’s medical history, when natural birth at home was more commonly practiced. Since the advancement of the state’s medical system, this option became marginalized—still accessed but certainly not as frequently as before. The state system became the premier and most subscribed option. However, home birth is being accessed more and more by people seeking safe, alternative natal care. Data from UNICEF tracking the number of deliveries in institutions between 2001 and 2011 shows a small but steady rise in deliveries outside of institutional settings. This resurgence of home birth is due in part to the advocacy of parents and midwives in Trinidad and Tobago to reclaim Indigenous practices and the autonomy of birthing people. Marcia Rollock, President of the Trinidad and Tobago Association of Midwives confirms, “we have found that home deliveries are once again gaining popularity.”
The history of the systemic transition to medically managed birth is tightly bound to Trinidad and Tobago’s colonial past. Colonial authorities undermined traditional non-European socio-political markers that included birthing practices. This was done through violence that began with European occupation of Indigenous territories, European enslavement of African peoples and the importation of indentured labourers into Trinidad. The policies enshrined in the colony usurped the Indigenous political authority and only recognized European systems of governance and health care. The resurgence of home birth and natal care guided by mothers and midwives is momentous; it marks an important period in contemporary health care in Trinidad and Tobago that is part of an unofficial regional movement focused on recognizing the ways in which colonial policies permeated all political systems in the Caribbean. In this regard, patient-guided home birth that considers and honours non-European traditional practices is part of the current movement towards decolonization in the Caribbean.
Today, nurse midwives trained in the conventional medical system are advocating for more autonomy from doctors—and more choices for mothers. Most pregnant women in Trinidad and Tobago deliver in public hospitals. Some have access to home birth through the free public system, and there is one natural birth center as well as a handful of private midwives who offer home birth support.
It was not Ma’s intention to become a midwife in the 1940s. If a woman in the village was making a child (giving birth) without any help, Ma Francisca delivered the infant. “We were all poor and there was nobody to help, so I went,” she says. In the mid-twentieth century Trinidad and Tobago’s public health care system had developed to accommodate natal care, but it was not uncommon for expectant mothers, especially those in rural areas, to use a local midwife due to tradition and, in some cases, superstition. Birth was integrated into communities—young people knew they were born at home and heard the calls of women as they birthed children in their neighborhood. The bodily practices and rituals around birth, variable in different communities, could not easily translate to the sterile hospital. There was also the problem of access. For rural women the option of going to a hospital was not practical because of the distance, so traditional midwifery services were used. Infrastructure at that time was also a challenge to rural communities. Roads were yet to be built in certain areas and the cost of travel was prohibitive for some, limiting the access of rural residents to essential services in urban centres.
Ma used to massage women’s bellies with oil to reposition babies and sometimes gave women glass bottles to blow into when they were taking pains (in labour) to help them manage the pain. Ma delivered one of her own babies and also experienced the grief of delivering her sister’s stillborn child. In her 80s, after she had retired from midwifery, Ma was called back to deliver her own granddaughter when, in premature labour, the mother could not make it down the mountains to the nearest hospital. Ma’s role in her community is part of a legacy of traditional midwives called “middies” who received training and mentoring in an oral tradition. Unlike institutional medical training programs, elders passed down information about midwifery to younger people in their communities. Ma also received informal instruction from a British nurse stationed close by in Blanchisseuse.
The story of midwifery and birthing in Trinidad and Tobago spans the legacies of Indigenous governance, colonial occupation, enslavement, emancipation, indentureship, and Independence in 1962. Between the 1500s and the 1700s, colonial violence decimated the populations of Indigenous communities including the Taino, Kalinago, and Warao nations. European weapons and disease undermined Indigenous efforts at resistance. Colonization subverted the political sovereignty of Indigenous nations from 1492 onward and their resistance to colonial occupation continues to the present.
In 1858, the British built the first hospital in Trinidad’s colonial headquarters, Port of Spain, and staff kept detailed annual records of births, illnesses, and deaths in what were called Blue Books. The British began training local nurse midwives at the hospital in Port of Spain and later in San Fernando. They also established the Extern Maternity Service in 1914 to dispatch nurse-midwives into homes for natal care.
Obstetric birth was introduced largely over the course of the 20th century. In doctor-facilitated birth, the doctor’s needs are often prioritized over the mother’s comfort. The ubiquitous practice of women delivering on their backs prioritizes doctors’ access to women’s bodies, rather than encouraging mothers to move around and find a position that is comfortable for them. Obstetricians are trained medical doctors who specialize in pregnancy, labor, and delivery and the medical interventions and surgeries that can be used. Midwives are trained to address the issues of standard, healthy pregnancies. In best practice, obstetricians are focused on treating high-risk patients while midwives support low-risk patients. In reality, in the hospital wards, women with low-risk births are expected to be on their backs in hospital beds, connected to IVs, and are not allowed to eat, just in case they need to be anesthetized for surgery. They are often isolated and under bright hospital lights alongside beeping machines and are in close quarters with others. Doctors lead the activity on the wards, and midwives are expected to follow their instructions. Doctors, nurses, and midwives come and go to care for the patients. Hospital wards are consistently described as stressful environments, and women are expected to follow the instructions of doctors and midwives. They don’t have the option of directing their experience. While many women have described very positive experiences in hospitals, others have described verbal abuse, neglect, and medical malpractice.
Despite the proliferation of medically-managed birth, middies continued to practice, especially in rural districts, and the new class of midwives trained as nurses in the medical system continue to advocate for natural birthing techniques when medically safe. Birthing is an inevitably unpredictable and complex process for mothers and infants, and it is even more precarious when women’s autonomy is subverted. Instead of mothers taking cues from their own bodies and desires, they are cautioned to put trust in doctors at hospitals, limiting the other options available to them.
The discrepancy between free, public, state-owned institutional health services and expensive private health care created a class division in natal care with wealthy people opting for private care and aspiring middle class people doing the same. Giving birth in a private hospital was viewed as both safer and more privileged, while home birth (either through public health services or through independent midwives) was thought of as backward and associated with the rural poor. Considered a remnant of the past, traditional and non-institutional birthing options came to be associated with low social status, while private hospitals represented affluence and progress.
Born in Trinidad in the 1940s, Cynthia’s Chinese-Trinidadian father sent her to be raised by her grandmother in China until she was 12. There she learned about medicinal plants in the mountains of China and later in northern Trinidad. She used plants such as the leaves of the Wonder of the World plant which was topically applied to injuries and hog plum bush vaginal steams after birth to clear the uterus. Cynthia gave birth to two children, followed by multiple miscarriages and one still birth in the 1970s and 1980s. She began to seek traditional and holistic approaches to pregnancy and birth, including visiting a local middie/masseuse and a natural doctor who prescribed traditional East Asian therapies and dietary and lifestyle changes. Eventually her baby, Fallon, was born in a private hospital in Trinidad with an obstetrician’s supervision in 1983.
When Fallon in turn became pregnant in 2019, she and her partner couldn’t decide whether they wanted to deliver at the public Port of Spain General Hospital where the care is free and supervised by doctors, or the less conventional midwife-led Mamatoto Resource and Birth Center, an NGO, and the only midwife-led birth center in the country. They took birth classes at Mamatoto but had reservations: What services could the midwives offer that doctors couldn’t and vice versa? If something went wrong, could they get to the hospital in time?
Fallon describes her attraction to thinking about birth from multiple medical perspectives. “A lot of [my mother’s birth story] is part of who I am—I totally believe that imprints from birth are real, they go beyond the physiological…down to these Asian and Japanese-influenced type of foods and practices,” says Fallon. Her story illustrates the generational transmission of birth practices and the meaning contained in birthing traditions. In Trinidad and Tobago many women still participate in post-partum practices passed down through their families. In particular, there is a commonly held belief that a woman’s body is vulnerable after giving birth and must be carefully protected; women are encouraged to avoid showering for the first nine days after delivery. Fallon’s mother sourced the hog plum bush she would need for her vaginal steams, as well as the mix of herbs she could use for a traditional bath nine days after birth. In addition to appointments with her obstetrician, Fallon mixed an essential oil for the baby by asking which oil they prefer and intuiting their reply. As Fallon awaited her baby’s arrival, her mother Cynthia prepared Fallon’s postpartum care. Fallon planned to spend a few weeks at her mother’s home immediately following the birth.
One traditional practice that is still commonly utilized in Trinidad and Tobago is the use of the leaves of the hog plum tree as part of natal care. Hog plum, Spondias mombin, is native to South America and the Caribbean. The tree is found all over Trinidad where it is kept largely for the production of its fruit, a small sour plum used for jams and juices. The leaves are used traditionally by midwives, “to help induce labor, reduce bleeding and pain during and after childbirth, to bring on the flow of breast milk, and as a vaginal wash to prevent or treat uterine or vaginal infections after childbirth” (Taylor, 2006).
Romana lives in the country outside of Port of Spain. When she describes her care and delivery at Mamatoto, she explains “You hear midwifery, you hear natural birth, and you’re thinking some haystack somewhere and it was the total, total opposite,” she says. Many assume that professionals like Romana, an accountant in downtown Port of Spain, would choose to deliver in a private hospital. But Ramona, who describes herself as a proud St. Lucian living in Trinidad, felt she needed more than the 15-minute appointments that her private obstetrician provided. After giving birth twice at Mamatoto Resource and Birth Centre, Ramona is planning her first home birth, even though it is often perceived as a rural, old-time thing. Dressed in white nursing uniforms, midwives Akilah and Ebony arrived and provided prenatal care to Romana as she lay in her own bed where she planned to deliver the baby.
At the birth center Romana found birthing rooms set up like bedrooms, a birthing tub (the only one in the Caribbean), and a comfortable waiting room for family and friends. Mamatoto also provided her with a doula, a trained support person. After a thorough medical screening, and with ongoing confirmation from her obstetrician, the midwives told Romana that her low-risk pregnancy was a good match for a safe natural delivery at the birth center.
The cost of birthing at Mamatoto is less than half of the starting rate for a private hospital delivery, which Romana estimated would have cost her as much as caring for her baby’s entire first year of life. Further, Romana knew that in Trinidad and Tobago, like in much of the world, the rate of Cesarean-sections is estimated at about three to four times that recommended by the World Health Organization. There are a variety of explanations for this, including that one intervention in the birth process inevitably cascades into more. For example, using medications to artificially quicken birth can mean that the mother’s body is not fully ready to deliver and may require additional medical procedures in order to do so. Both private and publicly-funded hospitals employ routine interventions that are often medically unnecessary—like shaving the pubis, using electronic fetal monitors which restrict women’s movement during labor, cutting the perineum to speed delivery, and denying women food in case they need to be anesthetized for emergency surgery. Mothers have been forced to sit up in a chair after delivering, putting pressure on their sore bodies, because their bed was needed for the next patient. A quick search of Trinidad and Tobago news stories reveals a slew of horrific headlines broadcast on national television and in newspapers about negligence and tragic loss of life during birthing procedures at public facilities. Debrah Lewis, the director of Mamatoto says, “We don’t like to share and promote the horror stories…our focus is on what we do and what we do differently and how we could make the experience better.”
Despite stigma around public health facilities and persisting ideas that the care is substandard, some believe that public medical facilities are better than private. Perhaps counterintuitively, many mothers who have experienced both public and private care report greater attention from the midwives in the public clinics than from their private doctors. Public medical facilities are not without issues, including overcrowding and limited staff. Also, in public hospitals women are not allowed to have someone accompany them while they are on the labor wards. Only when women are transferred to the delivery wards can one person, who has fulfilled hospital requirements, join them for the delivery. However, private hospitals routinely transferred women to the public system if extreme complications arose.
Private prenatal appointments are short and are often not as rigorous as screenings in public clinics. Women have reported feeling pressured to schedule their births through induction (a medical acceleration of labour) or Cesarean section in the private system. While there are situations where an induction or scheduled C-section is the safest choice, for most women an induction means that the birth process is rushed, often creating a need for further medical interventions. Lewis explained, “sometimes interventions are necessary and when they’re used appropriately and when necessary then it’s okay. But the problem is, the challenge is, that we’ve really begun to overuse interventions.”
For her third child, Romana opted for a home birth. “My mom was born at home. Her siblings were born at home. It’s only now we’re taking birth to the hospitals,” she says.
Contemporary midwives in Trinidad and Tobago today are quite different from traditional middies in terms of training and practice. Middies learned largely from older middies in their communities—or as Ma said, there was no formal training and they functioned independently of institutions. The doctor-led British health system that was established in Trinidad and Tobago excluded middies rather than incorporating their relevant folk-based expertise. Certain skills that middies practiced are not commonly taught to institutionally trained midwives and doctors. For example, if a baby is breech middies were often able to facilitate safe birth by repositioning the mother and rotating the baby inside the womb by massaging the mother’s belly. Most institutionally trained health service providers will not deliver difficult cases like these vaginally but will instead elect for a C-section. This major surgical step severely limits the new mother’s mobility as she cares for her baby after birthing.
While middies functioned independently, most midwives in Trinidad and Tobago now function under the supervision of institutionally-assigned doctors. These doctors make the final decisions about the type of care patients receive. This limits the role of the midwives, who bring alternative knowledge, treatment and experience to the birthing process. While the prevalence of home birth has declined in the decades since Trinidad and Tobago’s Independence in 1962, the process of birthing did not transfer seamlessly out of homes and into hospitals.
Today, the three home births each midwife must complete in order to be certified are the only times that most upcoming midwives have the opportunity to deliver babies without the supervision of a doctor. They are instead accompanied by a supervising certified midwife. Student midwives attest to the positive difference they witness between monitoring women birthing in the comfort of their own homes, with the people they choose to have present versus birthing on the hospital wards. In the care of midwives, women have great autonomy in the direction of the birthing process. While there has been a resurgence of the practice of home birth in Trinidad and Tobago many people are still not aware that it is an option, especially the fact that home births are free of charge when done with a student midwife.
The work of committed midwives has increased women’s access to non-institutional birthing options. The Amicus Birth Center was established in the 1970s by a group of midwives. Though Amicus closed in the early 2000s, Mamatoto Resource and Birth Center was established shortly thereafter. Private home birth midwives have continued to function in the country, though their services are not well-known and geographically limited. In 1995 a group of midwives established the Trinidad and Tobago Association of Midwives (TTAM), affiliated with the International Confederation of Midwives. TTAM focuses on improving midwifery education and advocates for midwives locally and regionally. TTAM also provides birthing classes at their center in Couva, central Trinidad. They advocate for greater autonomy for midwives, better relationships with doctors, and for improved hospital conditions.
A few days before her due date, at her final prenatal visit with her doctor, Romana’s doctor cleared her again for the home birth. The student midwives made their regular visit to Romana’s home. After listening to the baby’s heartbeat, the midwives leaned in closer. Something didn’t sound right. The baby’s heartbeat was irregular. “Even the doctor missed it. It was because the midwives took their time that they found it,” says Romana. The midwives accompanied her to the hospital to have the baby assessed further. Romana’s hopes for a home birth were dashed. The doctor at the hospital confirmed what the midwives heard, and scheduled a C-section for Romana’s delivery to avoid any stress for the baby. Romana was both disappointed and grateful. While her months of preparation for home birth did not pan out as planned, Romana had a successful surgery.
The advocacy of midwives and parents in Trinidad and Tobago has in effect operated towards a decolonization of natal care. Despite the colonial establishment of state-run and state-monitored health care systems that retained prominence since first established, there are still strong connections to traditional health care within birthing practices in Trinidad and Tobago and this retention is being utilized with positive effect in natal care. As a radical, decolonizing shift occurs across the board in policy in Trinidad and Tobago, the realities around birth—how babies are born, who delivers them, and where—are shifting, incorporating intergenerational knowledge that was interrupted by these systems—and moving towards mother-centered care that questions norms passed down through colonial and institutional influences.
Additionally, the Covid-19 pandemic has highlighted public health issues related to human contact. In the context of natal care, there is great concern for safety at public health facilities. While throughout the pandemic, home birth through the public system has been unavailable, the option of home birth is one which can reduce the risk of the contracting Covid-19 or any other virus by taking the birthing process out of the public facility. This not only increases the safety of parents and babies, it also decreases the traffic at public facilities and relaxes the strain on health care providers at those facilities. The revival of home birth therefore has the potential to serve not only the issues of patient autonomy in natal care but is also a measure that care be applied in the interest of public safety.
We thank the midwives, mothers, parents, community elders, and all the resourceful supporters who contributed to this research, especially Ma, Ramona, and Fallon for sharing their stories. Special thanks also to the Alliance of Rural Communities (Arc TT), Mamatoto Resource and Birth Centre, the Trinidad and Tobago Association of Midwives (TTTAM), the Institute for Gender and Development Studies (IGDS) and Kelly Fitzjames.
This article is a part of a body of work including the series Birth Stories of Trinidad and Tobago and a short film, Home Birth in Trinidad and Tobago, screened at the Trinidad and Tobago Film Festival 2019, Palm Bay Caribe Film Festival 2020, and the International Confederation of Midwives Conference 2021. Romana, featured in this article, appeared alongside Tammy Kremer in the TTT Now morning news show.
Francisca “Ma” Estrado died on January 13th, 2021, just twelve days before her 105th birthday.