Medical personnel help Jazmín Joaquín de la Cruz breastfeed, after she gave birth to twins by cesarean inside the Covid-19 unit of the National Institute of Perinatology (INPer) in Mexico City. Early on in the pandemic, treating Covid positive mothers became part of daily life for medical teams at INPer as doctors discovered that roughly one-quarter of all women admitted to the hospital were testing positive for the virus. During the height of the pandemic, INPer medical personnel encouraged Covid positive women to breastfeed when they felt well enough, provided that mothers wore a mask and face shield to protect the baby.

Medical staff in full Covid protection prepare Denize Yavkin, 29, for a Cesarean in the Covid unit of Mexico City’s prestigious National Institute of Perinatology (INPer). From early on in the pandemic, treating Covid positive mothers became part of daily life for medical teams at INPer as doctors discovered that roughly one-quarter of all women admitted to the hospital were testing positive for the virus. For Yavkin, being covid positive was the least of her concerns. Her pregnancy had been very difficult and rife with misinformation, until she came to INPer, she said, where the professional staff gave her more confidence.

A doctor pauses for a brief moment of silence between back-to-back Cesarean operations inside the Covid-19 Unit of Mexico City’s National Institute of Perinatology (INPer). Early on in the pandemic, treating Covid-positive mothers became part of daily life for medical teams at INPer as doctors discovered that roughly one-quarter of all women admitted to the hospital were testing positive for the virus. Typically, the Institute deals with high-risk births that require Cesareans.

A surgical team performs a Cesarean at the Hospital Regional Occidental in Quetzaltenango, Guatemala. Serving much of the Western Guatemalan highlands, he hospital is one of the three largest hospitals in the country, and among few that are equipped to handle high risk complicated births and obstetric emergencies.

Alerra Dagong López, 29 , reacts to seeing and feeling the presence of her newborn son, minutes after he was born via Cesarean at the Hospital Regional Occidente in Quetzaltenango, Guatemala. Serving much of the Western Guatemalan highlands, the hospital is one of the three largest hospitals in the country, and among few that are equipped to handle high risk complicated births and obstetric emergencies. Dagong did not anticipate or desire a C-Section, but doctors advised her that her amniotic fluid had become too low, posing a risk, she said.

Soldiers stand guard outside the Ometepec General Hospital in Mexico’s Guerrero state. When the Covid pandemic hit, state health authorities reconfigured many public hospitals, like this one, to create separate Covid and non-Covid sections, a move that fueled pervasive fear and anxiety across the region. As the pandemic intensified, the public sometimes stormed hospitals and threatened doctors, blaming them for the rising death rates. The Army was called in to protect medical personnel and maintain order in public areas.

Women give birth simultaneously in the General Hospital Dr. Donato G. Renacimiento, one of the most important maternity hospitals in Mexico’s Guerrero state, located in Acapulco. Due to its no refusal policy, the hospital is constantly oversaturated, creating challenging conditions for patients and doctors. Over the past decades, healthcare authorities in Mexico and worldwide have relied on strategies that force women to give birth solely in hospital settings, arguing that this protects women and reduces unacceptably high maternal and infant mortality rates. Although this focus on facility-based births and emergency care, inspired by the UN Millennium Development Goals, has saved lives, its side effect has been the development of a ‘hierarchical technocratic model’ that leaves all birthing decisions to doctors and often makes vulnerable women feel pressured to accept unnecessary medical interventions.

Babies from different mothers share space where beds are limited at the General Hospital Dr. Donato G. Renacimiento, one of the most important maternity and teaching hospitals in Mexico’s Guerrero state, located in Acapulco. The hospital is constantly overcrowded, creating challenging conditions for patients and doctors. Other factors, such as medicine and material shortages and high levels of violence in the region further complicate workflow at the hospital. Bed shortages are common, further limiting hospital staff to provide sanitary conditions and offer dignified treatment.

Resident doctors prepare a woman for a Cesarean at the General Hospital Dr. Donato G. Renacimiento, one of the most important maternity hospitals in Mexico’s Guerrero state, located in Acapulco. The use of the C-section worldwide has nearly doubled since 2000. Mexico has cesarean rate of almost 50 percent, compared with the World Health Organizations’ recommended country average of 15 percent. According to WHO statistics, approximately 85 percent of pregnant women should be able to deliver babies without medical intervention. Nevertheless, doctors in hospital settings continue to medicalize the birth process, leaving many women feeling disrespected with their opinions ignored.

Resident doctors perform a Cesarean at the General Hospital Dr. Donato G. Renacimiento, one of the most important maternity hospitals in Mexico’s Guerrero state, located in Acapulco. The C-section rate in Mexico is close to 50%, significantly higher than the 15 percent recommended by the World Health Organization. Some health officials have been keen to place professionally trained midwives in the state’s health centers and hospitals, in order to attempt to improve the quality of care women receive and to potentially reduce the number of Cesareans.

An emergency medical team attends a “code red” situation involving a birthing woman with signs of preeclampsia, in the triage unit of the General Hospital Dr. Donato G. Renacimiento, one of the most important maternity and teaching hospitals in Mexico’s Guerrero state, located in Acapulco. The hospital is constantly overcrowded, creating challenging conditions for patients and doctors. Other factors, such as medicine and material shortages and high levels of violence in the region further complicate workflow at the hospital. Some state health officials believe that integrating professionalized midwives into hospitals can improve the quality of service for women, alleviate overcrowding and leave specialists more time to deal with obstetric emergencies.

Nurses prepare a group of women for tubal ligation surgery at the General Hospital Dr. Donato G. Renacimiento, one of the most important maternity hospitals in Mexico’s Guerrero state, located in Acapulco. The women agreed to undergo free operations during the hospital’s one-day birth control campaign. The campaign was part of a broader family planning strategy by healthcare officials to reduce the number of unplanned pregnancies and potentially high risk births that could convert into obstetric emergencies.

Licensed Obstetrical Nurses (LEOs) receive specialized training on how to revive babies, as part of their perinatal nurse training. The venue for their coursework took place over a one year period at the Alameda Midwifery Unit in Chilpancingo, Guerrero (pictured). The unit opened in December, 2017 as part of an emerging national push to strengthen midwifery care in Mexico. The center’s multidisciplinary staff, including professionalized midwives, obstetric nurses, general doctors and a GYN, is considered pioneering by many. By providing safe, culturally appropriate reproductive health services based on the midwifery model of care to women with low-risk pregnancies, the center’s directors aimed to improve birth experiences and health outcomes for women, while reducing unnecessary medical interventions and overcrowding in nearby hospitals.

Gabriela Melendez, a nurse-midwife and the Executive Director of Asociación Corazón del Agua, tends to a woman in labor alongside current midwifery student, Ber nardina Alvarez Ramos (on far left), and midwife graduate Gloria Marina Ac Cacao (standing to Melendez’ right). The mother in labor, Sindy Marietta Oritz Moreno wanted to give birth naturally, at her home, in downtown Guatemala City, where she could be accompanied by family members and her husband, Juan Pablo Medina Castillo (pictured next to her on right). Melendez arrived with her team at 9:30 in the evening and began monitoring Ortiz’ labor. To create a more relaxing environment, she turned off the bright overhead ceiling lights.

Professional midwife Nohemi Luna Rojas (R) and midwifery student Rosario Martín quietly observe while Anayely Rojas Esteban, 27, tries giving birth in a standing position at the Alameda Midwifery Unit in Chilpancingo, Guerrero. The first hospital the couple visited denied them service, due to renovations in progress. Since they were loath to try alternative area hospitals for fear of Covid and eager to find a midwife instead, doctors suggested that they try the Alameda. They were thrilled with the service and happy to find midwives who allowed Rojas to have a vaginal birth, while choosing the birthing position that felt most comfortable to her. They also mentioned their relief that midwives did not perform a painful episiotomy, as doctors had done during her first hospital birth.

Professional midwife Alma Delia Felipe Hidalgo accompanies Maria Guadalupe Silva Tomás, 24, as she gives birth at the Casa de la Mujer Indígena Nellys Palomo Sánchez (CAMI), located in San Luis Acatlán de Juárez, a small town in the Costa Chica zone of Mexico’s Guerrero state. Silva and her husband preferred the CAMI over hospitals for the birth of their second child, for many reasons: because they had had a very positive experience working with the CAMI midwives during Silva’s first birth, because they felt hospitals were unsafe during the continued pandemic, and also because Silva wanted to experience a non-medicalized birth according to her customs, accompanied by her husband and parents.

Professional midwife Alma Delia Felipe Hidalgo weighs the baby of Maria Guadalupe Silva Tomás, 24, at the Casa de la Mujer Indígena Nellys Palomo Sánchez (CAMI), located in San Luis Acatlán de Juárez, a small town in the Costa Chica zone of Mexico’s Guerrero state. Silva and her husband preferred the CAMI over hospitals for the birth of their second child, for many reasons: because they had had a very positive experience working with the CAMI midwives during Silva’s first birth, because they felt hospitals were unsafe during the continued pandemic, and also because Silva wanted to experience a non-medicalized birth according to her customs, accompanied by her husband and parents.

A foal runs to catch up with its mother on the southern outskirts of Mexico City, near the home of Maira Itzel Reyes Ferrer, 26, who walks with her husband, Hugo Alberto Albarran Jarquin, 33, and her midwife, obstetric nurse midwife Elva Carolina Díaz, in an effort to advance her labor contractions. Reyes was eager for her husband to be able to experience every aspect of the birth. She was also determined to “change the paradigm” in her family by illustrating that a safe natural home birth is possible, she said. Her sister, mother and grandmother had all had Cesareans.

Obstetric nurse midwife Elva Carolina Díaz massages Maira Itzel Reyes Ferrer, 26, as her contractions begin to intensify, at her home, located on the southern outskirts of Mexico City. Traditional midwife Pilar Grajeda Mejía, 94, observes, along with Reye's mother, Mercedes Reyes Ferrer, 54, and the family’s three dogs, who also wanted to participate.

Obstetric nurse midwife Elva Carolina Díaz (R) and her grandmother ,traditional midwife Pilar Grajeda Mejía, 94, (L) urge Maira Itzel Reyes Ferrer to change positions to endure her contractions. She borrowed her dog’s bed to protect her knees. Reyes’ mother observes in background. Reyes and her husband had been considering alternative birth scenarios before the pandemic started, but the growing death toll over the summer solidified their decision to give birth at home with certified midwives. Reyes feared that she, her baby of her family could become infected with Covid in a hospital, or that doctors would force her to have a Cesarean. She also said she wanted to “change the paradigm” of giving birth in her family, since her sister, her mother and her grandmother had only experienced Cesareans and never a natural vaginal birth.

Hugo Alberto Albarran Jarquin, 33, comforts his wife, Maira Itzel Reyes Ferrer 26, during her final stages of giving birth inside their home in the south of Mexico City. Obstetric nurse midwife Elva Carolina Díaz (L front) closely monitors the escalating situation while Reyes’ sister (M back) helps traditional midwife Pilar Grajeda Mejía, 94 (R back) with her surgical gloves. Reyes mother (back, far left) curiously observes the unfolding scene. Reyes and Albarran had been researching alternative birth scenarios along with the concept of “humanized” birth before the pandemic started, but the growing death toll over the summer of 2020 solidified their decision to birth their son at home with certified midwives.

Finally more relaxed, Hugo Alberto Albarran Ferrer, 33, joyfully holds his newborn son, Ivan, born in the couple’s home on the outskirts of Mexico City, during the peak of the pandemic. He and his wife, Maira Itzel Reyes Ferrer, 26, had been researching alternative birth scenarios along with the concept of “humanized” birth before the pandemic started, but the growing death toll over the summer of 2020 solidified their decision to birth their son at home with certified midwives.

Maira Itzel Reyes, 26 (back) reacts with laughter while her husband, Hugo Alberto Albarran Jarquin, 33 (L) changes diapers, the day following the birth of their new son, Ivan. The couple felt jubilant after the two and a half day birth process. Díaz and her grandmother, also a midwife, accompanied them throughout the entire process. Left were only a few remaining accounting details including payment, signing papers for Ivan’s birth certificate, a final checkup for Maira and her baby, and a customary celebration breakfast of pancakes.

Javier Basilio Lara, 31. (L) greets Perinatal Nurse midwives (L-R) Guadalupe Hernández, Magdalena Laiza Daniel, and Margarita Marrón Escobedo as they arrive to accompany Basilio’s wife, Nayeli Balderas, 30, as she gave birth at their Mexico City apartment, during the peak of the pandemic. Balderas had assumed she would have an institutional hospital birth, like other women in her family and many of her friends. Yet, when the pandemic began to intensify, she and her husband decided to pursue a home birth with experienced nurse midwives, to minimize their risks and to avoid hospitals. They had been studying videos about humanized birth and midwifery, with its focus on honoring the natural birth process, and they realized that they preferred this model.

Perinatal Nurse midwife Margarita Marrón Escobedo comforts Nayeli Balderas, 30, during the initial stages of her labor inside her Mexico City apartment, during the peak of the pandemic. Balderas had assumed she would have an institutional hospital birth, like other women in her family and many of her friends. Yet, when the pandemic began to intensify, she and her husband decided to pursue a home birth with experienced nurse midwives, to minimize their risks and to avoid hospitals.

Nayeli Balderas tries to tolerate her intensifying contractions, comforted by her husband, Javier Basilio and perinatal nurse midwife Margarita Marrón Escobedo, inside the couple’s Mexico City apartment, where they decided to give birth to their first child during the peak of the pandemic. They had been studying videos about humanized birth and midwifery, with its focus on honoring the natural birth process, and they realized that they preferred this model. Other families came to the same conclusion, and midwives saw the demand for their services double or even triple during the Covid-19 pandemic.

Perinatal nurse midwife Guadalupe Hernández (R) uses the curtain to fan Nayeli Balderas as she works through intense labor pains, while supported by her husband, Javier Basilio Lara, 31, inside their Mexico City apartment where they decided to give birth. While their immediate families accepted their decision, some of their friends thought they were imprudent, and their gynecologist tried to instill fear in them, Balderas said.

Nayeli Balderas shrieks with emotion upon seeing her newborn son, born in a small private clinic at 4 a.m. in Mexico City. Balderas labored for 12 hours in her home before she and her midwives opted to go through with a cesarean, in order to reduce the chance of a possible obstetric emergency. The hospital had always been their “Plan B” and the midwives had introduced Nayeli to the doctor who would perform the surgery months earlier. Thus, when a Cesarean became medically necessary, Balderas entered the situation feeling confident.