OTAVALO, Ecuador — In a dimly lit room to the rear of San Luis Hospital de Otavalo, in the highlands of the Ecuadorian Andes, a young, labouring woman prepares to give birth.
Kneeling on a cushion, she holds firmly onto a rope suspended from the room's high ceiling. She presses her lips, writhing in suppressed agony at the onset of every contraction.
A nurse supervises two "midwives" — one rocking the labouring woman gently from behind and the other hugging her face forward. All this is intended to help her through the painful process; the rocking is meant to "straighten" the infant before it is expelled from the womb.
To the outsider this would seem an aberration, but roughly 360 babies are born this way each year at San Luis Hospital.
It's a case of Andean indigenous customs meeting modern medicine in the town of 90,000 inhabitants, where temperatures drop well below 15 degrees during winter in July.
The inter-cultural ward was opened at the nearly two-decades-old hospital in 2008 to encourage Otavalan women — largely victims of sexual and other forms of violence who resort to home deliveries — to have their babies at the hospital as part of efforts to bring Ecuador's high infant and maternal mortality rates in line with the Millennium Development Goal.
It is part of a wider project spearheaded by the United Nations Population Fund (UNFPA) that takes a human rights-centred approach to the sexual and reproductive health of indigenous peoples in Latin America. The UNFPA estimates that the majority of the average 85 maternal deaths per 100,000 live births that occur within Ecuador and other countries in Latin American and the Caribbean occur among indigenous women. Ecuador alone registers 96 deaths per 100,000 live births, according to its last Vital Statistics Yearbook.
The rate is just above Jamaica's, which moved from 110 in the early 2000 to 78 at present.
"We decided to adapt to their culture rather than change their customs," explains Dr Salomon Proano, who heads the hospital.
But that has been easier said than done. It took some convincing by the midwives — village women who neither speak Spanish, Ecuador's native language, nor have had a minute of classroom training in midwifery — to "sell" their "competence" to hospital administrators.
Fast forward four years, and today the project's success is heavily reliant on the 13 indigenous midwives and their ability to coerce other village people into using the inter-cultural facility, which is set up next door to a modern-day room with all the necessary equipment for horizontal births. They work closely with the maternity ward's five nurses and four doctors who have all had training in intercultural birthing and other indigenous medical rituals.
Dressed in their traditional garb that harks back to the 1960s — white, hand-embroidered flared-sleeved blouses tucked in long black skirts — the midwives readily boast that their skills are innate.
After all, they have delivered all their babies by themselves, and those of many other village people.
"We were born with the gift. We know how to measure the pulse, we feel the body, we know when the women are ready to push," Margarita Morales explains in Kichwa, the Otavalan dialect, her hair combed back in a pony tail and wearing layers of the gold-coloured beads, a familiar feature of the Otavalan custom.
"We got the knowledge from our ancestors. This is how they did things," she said.
The entire birthing process begins with cleansing the labouring woman of the "bad energy" — such as excessive yawning and high and low blood pressure she brings from her village — with teas and baths using a potpourri of indigenous herbs. So severe are some cases, they warrant the midwives playing bongo on the women's head and back with stalks of herbs tied together.
"When they have the bad energy, we can feel it ourselves," Morales explains through an interpreter. "We touch your head and detect the bad energy."
The expectant mother's head is constantly blown on to help the cervix dilate. The process moves over to three rungs on a wall, with the woman standing then moving down to a kneeling position on the lowest rung as the baby nears, and then to the rope from the ceiling. Since having babies is a family affair in Otavalo, fathers are usually on hand to cut the umbilical cord.
This birthing ritual relies heavily on an invisible force — gravity — which is believed to accelerate the baby's descent, significantly shortening the labouring hours.
"When you stand it takes half the time or less. It's very easy this way," says Morales.
Mothers are discharged as soon as their babies are born and given a clean bill of health.
While there are provisions for emergency surgeries, such as Caesarian sections in the case of severe complications, this too will take some coercion to change the women's mindset.
The UNFPA says that despite Ecuador's high maternal death rate, not a single death has been reported at the San Luis Hospital since 2005. The infant mortality rate, too, has dropped to under eight per cent, well below the national average of nearly 20.
"Maternal death rates have dropped to zero," says Diana Martinez, coordinator of nursing at the hospital.
Now the Ecuadorian government plans to replicate the project in other parts of the country, which has a population of just over 13 million.
"These midwives go into the village, identify the risk factors and bring the patients to hospitals and health centres," Martinez adds.
The successful project has won the hospital both international and national awards.
"It's a wonderful project," Martinez says, beaming with pride.