Soc. Sci. Med. Vol. 28, No. 9, pp. 925—944, 1989
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COSMOPOLITICAL OBSTETRICS:
SOME INSIGHTS FROM THE TRAINING OF
TRADITIONAL MIDWIVES
BRIGITTE JORDAN*
Department of Anthropology, Michigan State University, East Lansing, MI 48824, U.S.A.
Abstract In most countries of the third world, strategies for development in the health sector include
efforts to upgrade the skills of village level health care workers, including traditional birth attendants
(TBAs). In spite of several decades of experience, training programs for TBAs have not been particularly
successful. Drawing on data from several years of ethnographic fieldwork with Maya midwives in Yucatan
and on participation in government-sponsored training courses for indigenous midwives, this paper
examines some of the reasons underlying this failure. Paramount among these are differences in world
view and the misapplication of didactic modes of teaching in situations where learning in the
apprenticeship mode is more appropriate and culturally customary.
Key words—ethno-obstetrics, TBAs, models of teaching and learning
I. INTRODUCTION
The enterprise of teaching and learning, whether it involves midwives, school children, or an industrial
work force, is always an enterprise in the service of multiple agendas. Although it is ostensibly about the
transmission of knowledge and skills, in a hierarchically organized society it is also always about the
imposition, extension and reproduction of lines of power and authority. The mechanism through which this
process is carried out is the control and, indeed, definition of what constitutes ‘authoritative knowledge’,
that is, the knowledge which, in a particular context, is seen as important, relevant, and consequential for
decision-making. Training courses for indigenous midwives constitute one arena in which this
transformation is implemented and displayed. The export of cosmopolitan medicine has political effects as
does the exportation and imposition of western educational practices. Cosmopolitical obstetrics and
cosmopolitical education thus stand equally in the service of a political as much as a utilitarian agenda [1].
In this paper I am concerned with a set of interrelated issues. I begin with a detailed analysis of instruction
in training courses for village midwives in Mexico in order to raise questions about the nature of teaching
and, in particular, learning. I then consider general characteristics of two modes of knowledge transfer that
can be seen to act in competition in the education of midwives, namely the primarily formal and didactic
teaching common in official training courses, and the apprenticeship mode of learning, to which traditional
midwives are accustomed. I show that transformations in modes of learning and teaching are instrumental
in the redefinition of what constitutes authoritative knowledge within the domain of childbirth and suggest
that such redefinitions are consequential not only for the distribution of expertise but also for the
distribution of power and authority in a given social system.
At the current time, strategies for development in the third world include massive efforts to improve
maternal and child health. In most countries, such efforts include two kinds of thrusts: (1) family planning,
which is often considered the major vehicle for improvements, and (2) the ‘upgrading’ of perinatal services
to conform more closely to those of developed countries. Often, a central feature of both kinds of efforts is
the institution of training programs for traditional birth attendants (TBAs). TBA training is considered
important since local midwives will continue to deliver most babies for decades to come and are,
therefore, in a privileged position for providing contraceptive advice as well as perinatal care.
However, in spite of several decades of experience with training programs, such efforts, with few exceptions, have not been notably successful. It seems to be the case that the same failures and frustrations
are logged repeatedly in many different parts of the world. What I want to be concerned with here is an
*
Present address: Institute for Research on Learning, Xerox Palo Alto Research Center, 3333 Coyote Hill
Road, Palo Alto, CA 94304, U.S.A.
Jordan: Cosmopolitical Obstetrics
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analysis, based on careful participant observation, of some of the underlying reasons for this failure. In
what follows I draw extensively on my experience with midwife training programs in the state of Yucatan,
Mexico. I am convinced, however, from the literature as well as from talking to anthropologists and health
workers in other countries, that the problems I found are not confined to Yucatan but are generic problems
in developing countries. Nor are they confined to traditional birth attendants [2].
Before becoming involved in these training programs, I had the opportunity, during 8 years of off-and-on
fieldwork, to study Maya ethno-obstetric practices in detail [3]. In the community where I worked most
extensively, I routinely accompanied the midwife to births as well as on prenatal rounds and postpartum
visits. People made sense of our continuous association by seeing me as her apprentice. Doña Juana, my
mentor, often treated me that way as well, even though I took every opportunity to insist that I was there to
study what they did, not to become a midwife myself. While it is clear that there are substantial differences
between an apprentice midwife who would one day take her place in the community and an
‘anthropologist-apprentice’, I nevertheless feel that much of her interaction with me was close to what it
would have been with a local apprentice. My collaborator, Nancy Fuller, and I also recorded Doña Juana’s
life history, which details how she herself became a midwife, and I have talked to many of the TBAs in the
region about their acquisition of midwifery skills and knowledge. I thus believe that I have a fair
understanding of what the process of becoming a midwife in a traditional community entails, what
methods midwives use, the conditions under which they work, and how they and the women in the
community think about the process of childbirth. In the course of my fieldwork I also spent extended
periods doing participant observation at two different hospitals in the region and was thus quite familiar
with the particular version of cosmopolitan obstetrics that was practiced in the area.
2. TBA TRAINING COURSES IN YUCATAN
I first began to think about cultural differences in ways of learning when I was asked to participate in
training courses which the Mexican Ministry of Health and the National Indian Institute (INI) organized to
‘upgrade’ the knowledge of village midwives. In 1979, I served as a consultant on two such programs. The
first focused on family planning, the second on pregnancy, birth and the postpartum period. I not only
attended the official sessions but also spent a lot of off-duty time with the trainees. During classes I sat
with the midwives rather than the staff. In the evening, when the teachers went home, I stayed to eat with
the midwives and I brought my hammock to sling next to theirs in the dormitory assigned to them. Though
I was asked to serve as a ‘consultant’, it was never quite clear what my role was to be or what my specific
duties were. I self-defined my task as doing detailed participant observations of the courses and providing
input to the staff regarding the cultural and biomedical appropriateness of the training. Though I spent
most of my time with the midwives, there were occasions before, during and particularly after daily
sessions and at the conclusion of courses where I had extended discussions with the staff about ways in
which I thought the training could be improved. Throughout, my major objective was to understand what
this whole enterprise looked like from the point of view of the trainers and the trainees and in what ways
they made sense of what they were teaching or what they were being taught.
The midwives were drawn from the surrounding area with the idea that each community should send one
midwife and that this midwife should be literate and no more than 50 years old. In one case the course
took place at a regional hospital; in the other, in a hut commandeered for the purpose in a small village.
The courses lasted from 2 days to a week, and in the latter case the midwives were given a small stipend
to attend. The lesson plan was provided by the Ministry of Health. It specified various discussions,
lectures, slide presentations and exercises and was concluded by an examination, followed by the
graduation ceremonies, at which time the midwives received a certificate. I was particularly interested in
these training courses because most of the midwives I had encountered in my fieldwork had attended
such courses. Some of them had received UNICEF midwifery kits [4] and in talking to them and attending
births, I continually ran across evidence of biomedical influence. Midwives talked about vaginal
examinations; one had a thermometer which, however, she couldn’t read; others tries to convince me that
they sterilized their scissors before cutting the cord. I picked up considerable evidence that what I
presumed was being taught in those courses was not translated into practice as I observed it. And so I
had wondered for a long time just what the nature of the information was that was imparted at these
training sessions.
I want to make clear from the outset that the teaching staff—doctors and nurses from the regional hospital
and representatives from the Ministry of Health—were dedicated people who were convinced of their
mission and worked hard to impart to the midwives the knowledge they felt they needed. The midwives,
for their part, came with a sincere desire to learn and to ‘better themselves’. Thus, when I talk about the
problems that became evident, what I have to say should not be heard as laying blame at their feet. Nor
am I engaged here in a discussion of personal inadequacies, or even of the failure of these particular
Jordan: Cosmopolitical Obstetrics
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programs; rather, my aim is to identify some of the generic difficulties from which programs of this type
suffer, of which these particular courses are only more or less typical instances.
What, then, is the nature of the problems that emerged in the training sessions?
3. GENERIC PROBLEMS IN TRAINING COURSES
3.1. Instructional mode
3.1.1. Tuning out. For the first course, which dealt primarily with family planning, the midwives were
assembled in the lecture room of the regional hospital. In this course, as in most others, most of the
teaching activities consist of imparting straight didactic material, using mini-lecture (and sometimes maxilecture) format. The staff follow a kind of lesson plan which mandates a series of presentations, each of
30 - 60 min duration.
Any time one of these lectures begins, a series of significant behaviors on the part of the midwives can be
observed. As the lecturer launches into her or his presentation (e.g. the talk on “How is the IUD
positioned? The IUD is positioned in the uterine cavity, preferably when the woman is menstruating.. .”
etc., etc.) the midwives shift into their ‘waiting-it-out’ posture; they sit impassively, gaze far away, feet
dangling, obviously tuned out. This is behavior that one might also observe in other waiting situations,
such as when a bus is late or during sermons in church.
One wonders whether the reason for this behavior is that the midwives do not understand what is being
said. It is true that in this particular case several of the women spoke Spanish only marginally, certainly
not with sufficient fluency to understand formal or technical language. However, when this was recognized
later in the training course and one of the midwives was recruited to repeat the lecture in Maya, there was
no great change. I began to wonder if this tuning out had to do with the format of the lecture. Interestingly,
this type of display stands in marked contrast to the animation and lively engagement the midwives show
when they are allowed to actually do something, like practicing the approved procedure for washing
hands, rearranging chairs, going to the postpartum ward in the hospital, or when they are engaged in
discussion.
3.1.2. Emphasis on definitions. The lack of engagement generated by formal lectures is further aggravated by a preference for teaching abstract principles, especially definitions, rather than useful skills.
Hours of instructional time are taken up with sequences like the following:
Nurse to group: “What is a family?” This is a rhetorical question to which no
answer is expected or offered, though nobody would doubt that midwives know
what a family is. The nurse provides the answer: “A family is a group of people
who live under the same roof and have as a common goal the desire for a better
life.” Nurse writes definition on blackboard. There is little response from the
audience. Most continue to stare vacantly. Nurse looks expectantly at them,
strongly conveying the notion that the definition should be copied. She asks why
they aren’t writing. A number of reasons are given: “Forgot to bring a notebook.”
“Do not have a pencil.” “Can’t write.”
The nurse produces some pencils and paper. Then she walks around the room to check on progress,
which is elusive. Finally, the entire staff, one physician and two nurses, are engaged in copying the
definition on little slips of paper which they give to those midwives who can’t read or write. When,
mystified, I asked the doctor why he was doing this, he said “she can’t write” as he proceeded to copy.
When I pointed out that she couldn’t read either, he allowed that that was so, but thought when she goes
home, somebody may read to her what he had written down. The midwives are told that they should know
what is on the paper because it will be on the final test. Then we go on to the next definition which is
concerned with the question: “What is a home visit?”
Though one can imagine instances where certain facts have to be committed to memory, e.g. on what day
in the menstrual cycle to start the pill, it is difficult to see what impact memorizing these definitions could
have on midwives’ work. I will argue below that such verbal information is likely to be recalled only as
such, that is, as talk, without any implications for behavior.
Jordan: Cosmopolitical Obstetrics
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3.1.3. Appropriateness of course content. Throughout the course there was little evidence that anyone
had seriously considered the relevance of course content to midwives’ work and work circumstances. The
curriculum was modeled on the standard sequence of instruction in medical education. It proceeds
(chrono)Iogically from ovulation to conception and implantation, treats extensively the development of the
embryo and the fetus throughout the 9 months, and finally ends up with labor, delivery, and the
postpartum period.
Large portions of the sequence have no bearing on the tasks which midwives perform and consequently
contribute little to any upgrading of their skills. Knowing about the intricacies of ovulation or the hazards of
the sperm’s travel through the fallopian tubes is not information which contributes to their midwifery skills,
nor is it likely to be an asset if they try to explain family planning to the women of the community.
Traditional methods of dealing with problems of infertility and unwanted pregnancy are primarily herbal
and manipulative and cannot be improved by this information. At the same time, an important opportunity
was missed. In Yucatan, as in many parts of the world, women believe that the most fertile time is
immediately before and after menstruation, because at that time ‘the uterus is open.’ Women who want to
avoid pregnancy will have intercourse at midcycle when they believe the uterus to be closed—exactly at
the most fertile time. The medical staff, however, were not aware of this belief and, anyway, there was no
space for discussing it in the lesson plan. So the family planning course failed to impart the single piece of
information which could be expected to have significant impact on contraceptive behavior. Yet, there is no
easy solution here and the formulation I have just provided glosses, in many ways, the real difficulties.
From the point of view of the staff who had discussed ovulation and conception, the behavioral
implications (i.e. to abstain from intercourse at mid-cycle) followed as a matter of course. From the point of
view of the midwives, there were now two explanatory systems in place. The biomedical model, the one
they learned in the training course, was entirely unrelated to anything in their experience; the other, the
familiar indigenous model, was richly connected to their daily lives. It is often referred to in routine talk
among couples and midwives on occasions when fertility and infertility matter not as abstract discussion
topics but in regard to the behaviors people would engage in who did or did not desire to conceive. So the
problem goes deeper than not providing a discrete bit of information about fertile times. Rather it has to do
with the inattention to, indeed the invisibility of, the indigenous obstetric knowledge system for the medical
staff.
Much of the material concerning ovulation, conception, and embryology could have been eliminated and
instead the course could have focused on uterine and birth canal anatomy, and the process and mechanism of labor, with special attention paid to indications of abnormal developments (to the extent that they
are diagnosable by the midwives). For example, normal embryonic development could be taught with a
view to recognizing the symptoms of extra-uterine pregnancy; normal presentation could be taught as an
aid for recognizing malpresentation and what to do about it, etc.
3.1.4. Visual literacy. While course content is mainly communicated through abstract talk, this is on
occasion alleviated by showing various artifacts (such as contraceptive devices) and by audiovisuals.
Sometimes lecturers would hold up illustrations in books. Slide presentations were an important, eagerly
awaited feature of both courses. However, they may have done more harm than good. First, there is the
well-known problem of showing locally inappropriate materials, such as delivery in a bed—which is less
than helpful for the midwives since none of their clients have beds. (They give birth in a hammock, on a
chair, or kneeling on a mat on the floor.) But there is a more fundamental problem in that pictorial
representations may not be read in the way they are intended.
The iconographic traditions of nonwestern societies have different conventions than ours: which aspects
of the natural and supernatural world are represented and how that is done varies considerably crossculturally. Westerners may find it difficult to ‘read’ the pictorial representations incorporated in African mud
paintings, American Indian pottery incisions, or Maya temple frescos, though people who are familiar with
those iconographic systems have no trouble establishing what their real-world equivalents are. Similarly,
our customary ways of depicting objects and events may not be easily understandable to people
socialized into different iconographic traditions. Our own iconography, especially our scientific tradition,
has developed photographic representations to a very high degree, making us familiar with the various
transformations this medium allows, such as increasing or decreasing the size of the object represented,
decontextualizing it by blanking out the background, changing colors in certain ways, and so on. We also
subscribe to a set of rules for interpreting line drawings and sketches, having learned (though never in an
explicit way) what parts of the world they refer to, which pieces they disregard, just exactly how they
simplify. Members of any particular cultural tradition learn about such iconographic representational
systems early and usually without formal instruction [5].
The effect of this is that midwives who participate in their own but not our tradition of representation, may
not translate a line drawing into its real-body equivalent. A disembodied uterus on the screen may be for
them nothing more than a disembodied uterus on a screen. It has no necessary connection to the object
Jordan: Cosmopolitical Obstetrics
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they are used to palpating in a pregnant woman’s abdomen. Similarly, they do not readily understand our
peculiar convention, according to which an object that looks like a tennis ball on the screen represents
something invisible to the naked eye (the ovum).
By the time of the second training course, I had begun to pay close attention to the midwives’ reaction to
various types of presentations. When they watched the slide show on conception, where an ovum is
approached by several spermatozoa, they seemed politely attentive but nonplussed by the news that this
is how a baby starts. During a break, standing outside the hut away from the staff, I asked one of the
midwives: “So what did you think about the slides we just saw?” She allowed that it was pretty interesting,
especially the ball and the little sticks. “But,” she said with an air of confidentiality, “here in Yucatan we do
it differently. Our men have a white liquid that comes out of their penis and that’s how we make babies.
Not with little sticks (palitos) like the Mexicans and gringos do.”
This absence of our kind of visual literacy is a source of miscommunication that is exceedingly difficult to
identify. In particular, representations of objects which are very small, very large, or very far away, may be
difficult to make sense of. I am reminded of an incident with Doña Juana which highlighted this issue for
me. Doña Juana had been to the airport several times, had seen airplanes at the airport on several
occasions, and had actually seen us go up the steps and through the door, waving goodbye to her. One
day, walking in the countryside, a tiny silvery jet passed overhead. She began musing about how it is so
little and yet so big and finally said: “You know, what I always wonder about is how they first shrink it and
then blow it up again when it comes down.”
3.1.5. The transferability of verbal knowledge. It is important to realize that for persons with little or no
formal schooling the purely verbal mode of knowledge acquisition is problematic. In everyday life, in
contrast to formal education, skills are acquired by watching and imitating, with talk playing a facilitating
rather than a central role. Midwives in the traditional system are accustomed to learning experientially.
They are ‘parteras empiricas’, that is to say, they have acquired their skills by ‘going around’ with an
experienced midwife and by carefully monitoring the course and outcome of the births that they attend.
Talk in such situations is always closely tied to, and supportive of, action. In the traditional system, to
know something is to know how to do it, and only derivatively to know how to talk about it. Talk is never
primary.
Given this situation, there is a real question about the transferability of knowledge acquired in the verbal
mode to real-life situations where it is likely to get swamped by previously acquired behavioral routines.
There is some evidence that information learned in the verbal mode is used again in the verbal mode, in
talk, and is unlikely to be translated into other behavior. What is generated, then, is a new way of talking,
rather than a new way of doing. For example, one midwife began to refer to the uterus as the ‘prolapso’
after she had attended a training course. This term probably came from a discussion of ‘prolapsed uterus’,
but it is noteworthy that the midwife had not acquired any way of dealing with this complication. What the
course had provided for her was simply a fancier and more prestigious way of talking.
At this point, little information exists concerning the actual impact of training courses beyond casual
observations and anecdotal accounts, including those of anthropologists. What I observed in working with
midwives who had attended training courses is that they had learned how to talk to representatives of the
official health care system. They had learned what kinds of things were ‘good’ and what kinds of things
were ‘bad’. They had become exposed to an ideology which they knew was powerful, which commanded
resources and authority, and to which they could now better accommodate. Specifically, they had learned
new ways of talking, new ways of legitimizing themselves, new ways of presenting themselves as being in
league with this powerful system, which, however, had little impact on their daily practice. I believe that the
major effect of training courses, of the kind I have described, is a new facility to talk in the language of
biomedicine. For example, when the staff asked the midwives if any of them did external cephalic versions
or engaged in the traditional practice of cauterizing the umbilical stump of the newborn, none of them
admitted to doing it. They all were able to say that in case of breech presentation you refer the woman to
the hospital and for treatment of the cord you use alcohol and merthiolate. But when we were alone,
swinging in our hammocks at night in the dormitory, and I intimated that I actually knew how to do those
things and thought they were good for mother and baby, every one of them admitted that she engaged in
those practices routinely. As a matter of fact, a lively discussion and exchange of information about
specific techniques ensued. I would suggest, then, that current teaching methods produce only minimal
changes in the behavior of trainees, while, at the same time, providing new resources for talking about
what they do. In particular, midwives learn how to converse appropriately with supervisory medical
personnel, so that when the public health nurse visits to check on them, they can give all of the
appropriate responses to her questions [6]. Training courses may actually serve to provide the semblance
of medical legitimization through the bits and pieces of exotic medical gadgetry and terminology which
midwives pick up without concomitant change in behavior. The new knowledge is not incorporated in
midwives’ behavioral repertoire; it is verbally, but not behaviorally, fixed.
Jordan: Cosmopolitical Obstetrics
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3.2. The tools of the trade
One important message imparted to the midwives in both courses was that there are certain artifacts that
are indispensable for competent performance in the eyes of the medical staff. In the family planning
course, those were the artifacts of contraception, such as pills, IUDs and condoms, which were shown to
the midwives mounted on a display board held up by the nurse. They were not available for manipulation
or detailed examination. For the course on birth attendance the required artifacts consisted of the contents
of the UNICEF midwifery kit, such as scissors, brushes for handwashing, eye drops, etc. The curriculum
assumes that such tools are available to the midwives. As a matter of fact, the promise that midwifery kits
will be distributed is a major incentive for attending a training course. A good deal of course time is
allocated to teaching proper treatment of the kit and its contents. The midwives find out from others who
have been lucky enough to get such a kit, or from the audio-visuals presented during the training course,
that to properly attend a birth means to utilize scissors, clamps, suction bulbs, etc. Thus the gadgets
become increasingly important to them, if not for their actual use value, then definitely as visible symbols
of their expertise.
In the training course on birth attendance these items were not available for distribution to the midwives.
We went through the entire handwashing sequence, with the midwives diligently practicing how to scrub
with a handbrush. But when I asked if they thought they would do this at their next birth, it turned out that
they had no brushes. I knew that the standard Maya object for scrubbing is a wad of henequen fibre,
made from the leaves of the agave plant. So we repeated the whole routine using the local implement
which would always be plentifully available in any household.
Where the system cannot provide the tools whose use is portrayed as central to the execution of the task,
midwives are left with a deficient view of their work, simply by virtue of the fact that they do not have
access to the medical tool kit. To teach them, explicitly or implicitly, that in order to do a proper delivery
they should use resources unavailable to them undermines their confidence that they can manage at all.
Inattention to local contingencies and conditions manifests itself in a variety of ways. In another course,
midwives had learned to sterilize scissors. But they usually deliver babies in a hut where boiling water is
not available. So what one observes in actual births is that when the midwife asks for boiling water,
someone brings her a bowlful of water from a kettle which hangs over an open fire in a separate cooking
hut. She may dip the scissors into the water—and that is what midwives refer to when they answer ‘yes’ to
the question: ‘Do you sterilize your scissors?’ Another way in which local relevances are not taken
seriously is evident in the out-of-hand dismissal of traditional tools and techniques, without consideration
of their effectiveness. Thus external cephalic version (turning the baby from a breech position to a
cephalic presentation) and cauterization of the umbilical stump with the flame of a candle, both beneficial
indigenous techniques, were condemned without explanation [7].
It is indicative of the symbolic value of the midwifery kit, as well as of the shortness of supplies, that for the
closing group photograph of the training session the midwives were given simulated midwifery kits,
actually crudely painted, already rusting metal boxes. There was nothing in them. As soon as the picture
was taken, they had to give them back. In many ways, the fake kits symbolize what happens in these
courses: much revolves around different kinds of equipment, but in a serious sense the midwives walk
away empty-handed.
3.3. Evaluation of the effects of training courses
To evaluate what the midwives had learned, a written objective test was administered at the conclusion of
the training session. It was conducted in the same ‘collaborative’ mode that I described earlier, that is to
say, the staff ‘helped’ fill out the questionnaire. All of the midwives passed. The course was officially
concluded with a ceremony during which certificates were awarded to the midwives, an occasion that was
attended by all the dignitaries that could be mustered, including the participating anthropologist. That such
tests do not measure what they are intended to measure does not need belaboring [8]. On the other hand,
they do function in official statistics, i.e. the test makes it possible to certify that a certain number of TBAs
have been trained, which extends coverage to a certain number of communities, etc.
If one were interested in a tough measure of the effectiveness of these training courses, what one would
want to measure is the extent to which teachings are incorporated into the midwives’ behavioral repertoire
after the course is over. What is measured, in fact, is the degree to which midwives are able to reproduce
definitions, lists, and abstract concepts. In other words, if these tests measure anything at all, they
measure changes in linguistic repertoire and discourse strategies.
Jordan: Cosmopolitical Obstetrics
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For measuring behavioral effects, simple interviewing is inadequate. What is required are detailed
observations, most validly by someone who has the midwives’ confidence and is allowed to accompany
them on births and pre- and postnatal visits, since the only way one can find out about utilization of what
they have learned is to be there on actual occasions of use. Semantic data, those generated by asking
questions, are useless. It is not that the midwives lie; it is that they have acquired some measure of competence in the privileged discourse of biomedicine. As competent social actors, they adjust their way of
talking to the person they are talking to. When a doctor speaks to them, they don’t discuss the tipté (an
ethno-anatomical organ explained below), they don’t talk about a women dying of ‘susto’ because she had
twins, they talk about sterilizing their scissors and referring women with edema to the hospital.
What is important is that this problem is entirely hidden from the medical staff. It is simply out of their
awareness. They compile their statistics, they fulfill their quotas as to numbers of TBAs to train, they
check on the condition of the UNICEF kits, but the trainers never appreciate the ways in which the
statistics they compile have little to do with reality. They orient to the statistical requirements of the
national bureaucracy and when they go out into the communities they carry with them a way of looking at
the world which the midwives, while they don’t share it, at least can now discuss in appropriate terms.
From the illustrations I have provided emerge a range of issues which I would suggest underlie the
difficulties encountered. I will discuss two in some detail: the first is a difference in world view between
those who do the teaching and those who are taught; the second has to do with the didactic teaching
mode adopted in these courses which differs so fundamentally from midwives’ customary mode of knowledge acquisition. Both issues are salient for the design of educational interventions.
4. DIFFERING WORLD VIEWS
Trainers and trainees in these courses subscribe to sometimes clashing, sometimes subtly but crucially
different views of the world, of social relationships, and of bodily structures and processes. The curriculum
ignores these differences and, instead, imposes its own view of reality, seemingly without any awareness
that new information is not poured into a vacuum but interacts with a coherent and entrenched ethnoobstetric system of birth management. This is more than simple lack of cultural sensitivity on the part of
trainers who are often well-intentioned people. Rather, the problem is in some fundamental way invisible
to them.
The staff function, and see themselves, as representatives of biomedicine, of science, of the central
government and its institutions, and of progress and development. When operating in this official mode,
they dismiss the relevance of any other mode of being in the world. I spent long hours with the staff
explaining to them in detail some of the misunderstandings that had occurred in the course. On some
level, they must have been aware of what goes on all around them since only a small proportion of births
ever reach the hospital. Yet they professed sincere surprise when I showed them videotapes of births in
their own communities, the kinds of births that happened, for example, in a hut less than a block away
from the hospital. They simply dismissed that sort of thing as not relevant to the enterprise they were
engaged in. When I asked them, at one point, why they didn’t do external cephalic versions for breech
presentation rather than the dangerous C-sections, the response was: ‘Since we are doctors, we don’t do
that.’ What we see here are the effects of a thorough socialization into the profession of medicine and
beyond that, into a development mentality which, by definition, dismisses the views and practices of the
indigenous system.
When they encountered difficulties in implementing programs, or when they met with resistance by
midwives and women who refused to go to the hospital for birth, they saw the reasons in ignorance. They
had no appreciation for the ways in which their attitudes and procedures ran counter to deeply entrenched
local notions about the nature of birth. They had never considered the implications of the fact that birth for
Maya women is a normal life cycle event which does not fall into the medical domain in the first place.
That for such women the presence of husband, mother, and other women was important, simply had not
occurred to them. At the same time, it should be realized that who is present at birth is not merely a
question of personal or cultural preference but rather has serious implications for the outcome of birth.
Recent biomedical research shows that the presence of a familiar support person (a doula) during labor
has beneficial effects on outcome, decreasing the length of labor and substantially reducing fetal and
neonatal complications [9]. This is now widely acknowledged in western obstetrics where the presence of
fathers and other support persons has become standard in most countries. Because of the substantial lag
in the diffusion of innovation in medical practice, countries in the developmental backwaters of the third
world frequently practice a type of medicine that is outmoded in the very place where it originated.
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Trainers also are ignorant of ethno-anatomy and ethno-physiology. I already mentioned local beliefs about
fertile times in the woman’s cycle. Another notion that the staff did not know about is an organ called the
tipté, for which the scientific system contains no real equivalent. The tipté, the most important organ in
Maya ethno-anatomy, is located under the navel where one can feel it pulsating. They say it is “the
machine that makes the body work” [10]. One reason women in the area are doubtful about sterilization
even when they want no more children, is that this would involve operating in the area of the tipté. And
since they know that doctors don’t know anything about the tipté, they are not going to let them cut around
such a vital organ which might easily be injured. For them, a simple tubal ligation is the equivalent of brain
surgery for us—performed, moreover, by a surgeon who has no idea that the brain is a crucial organ.
Native knowledge about the tipté powerfully influences not only attitudes towards contraception but also
plays an important part in the traditional postpartum treatment of the mother. During childbirth, the tipté is
likely to get pushed out of shape and it is one of the most important tasks of the traditional midwife to ‘fix’
(componer) it during her last postpartum visit. If this is not done, the woman will suffer from headaches
and loss of appetite, will become weak and thin, and will not have enough milk for her baby. Later on, her
capacity to conceive will be impaired [11]. Women know that doctors are ignorant of the tipté and will not
talk about it when discourse is defined as medical.
It would also be helpful for the instructional staff to know that Maya women in labor often push too early.
This is due to the indigenous notion that labor is, literally, ‘work’. Because of this premature exertion,
women sometimes get exhausted before pushing is effective, leading to demands for ‘injections of
strength’, oxytocin [12]. This is a dangerous procedure for mother and child which can lead to a
precipitous birth with injury to the infant and, in the extreme case, uterine rupture.
Secularized cosmopolitan biomedicine is also blind to supernatural influences during birth, while the
indigenous system recognizes that birth is a vulnerable time for mother and child. Midwives, whose calling
traditionally is sanctioned by supernatural forces, are also supernatural specialists who know how to guard
against such dangers [13].
One could draw up a lengthy list of crucial topics of which the staff are ignorant. The placenta, for
example, is thought of as the ‘companion’ of the child by the local people. How it is treated is believed to
influence the health of the baby and it is the father of the child who has the duty of burying it in an
appropriate place, so that no harm will befall his daughter or son.
I would argue that underlying the medical staff’s blindness to the cultural and material realities of people’s
lives is an imperialist view of the world which simply dismisses the local culture and its solutions. This
attitude, of course, in no way is to be thought of as the personal deficiencies of staff members. Rather it is
inherent in their socialization into the medical profession which claims reproduction as one of its areas of
expertise.
What we find, then, because of the devaluation, dismissal and, indeed, invisibility of the indigenous ethnoobstetric system, is that the idea of a mutual engagement and a joint attempt at the solution of problems
never emerges. Authoritative knowledge here flows from the center to the periphery, from the top of the
medical hierarchy to the community-based auxiliaries. True reciprocal teaching, the notion that midwives
might have something to teach to medical staff, is unthinkable within this hierarchical framework [14].
5. KNOWLEDGE ACQUISITION IN THE EXPERIMENTAL AND DIDACTIC MODES
Beyond the issue of differences in world view I want to suggest another, largely unrecognized problem in
training courses for community level health care workers. I will argue that one crucial reason for the failure
of training programs lies in fundamentally different means of knowledge acquisition: the didactic mode of
formal teaching which is used in western-style training, and the experiential mode of apprenticeship
learning to which midwives are accustomed. In the following sections I broaden my concerns beyond the
special difficulties traditional midwives experience when they interact with western-style pedagogy and
explore the characteristics of the two modes.
5.1. Evolutionary and historical perspectives
Apprenticeship learning is based on imitation and behavioral matching. It is ancient for the human species
and is rooted in our evolutionary history. Learning through observation and imitation rather than following
genetically programmed action sequences is important in all higher social animals, but it is humans who
have developed this propensity into the primary modality for the acquisition of skills. This pronounced
capacity for responding to and learning from conspecifics may have been a crucial factor in the
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development of language, of tool use, and of complex social structures. Indeed, when viewed from an
evolutionary perspective, the capacity to learn about survival strategies in the widest sense is the human
adaptation [15]. This adaptation is reflected in specific evolutionary changes in brain size and structure,
and in prolonged immaturity—both of which contribute to plasticity in learning. It is an adaptation that is,
moreover, fundamentally based in social interaction. It is clear that now and for a long stretch of our
evolutionary past, the overwhelming bulk of behaviors, from feeding to grooming, is and has been learned
in this way, rather than being genetically based.
To appreciate how pervasive and important this mode of skill and knowledge acquisition is in contemporary humans, we need only consider that all childhood socialization, including the acquisition of language and of the skills of daily living, depends on the ability to imitate and the motivation to do so. This is
particularly evident in childhood play [16]. In later life as well, most learned action sequences depend on
behavioral matching: how to drive a car, how to give a lecture, how to behave at a cocktail party—for all of
these activities the knowledge required to bring them off unproblematically is acquired through bodily
imitation.
By contrast, didactic teaching, the verbal communication of abstract knowledge removed from its
occasions of use, is at most a few thousand years old. We know that in ancient Greece a teacher’s
disciples would sit at his feet listening to him expound general principles. Similar activities may have taken
place in ancient Egypt and Babylonia. It may be the case that a necessary condition for the appearance of
the didactic mode is the rise of specialists in whom a store of abstract knowledge has become located that
needs to be passed on. Yet we know that some specialists, such as traditional healers and, indeed,
midwives rely on teaching by example and on occasions of use. This would suggest that the critical
condition is the verbal nature of what is to be conveyed. On the other hand, the verbal material of ballads
and tribal histories was not taught didactically. As nursery rhymes today, such lore was acquired and
perpetuated through pattern imitation in the situations in which tellings naturally occurred, i.e. sitting
around the camp fire, at clan gatherings, during important life cycle events and so on. Whatever the
origins of the didactic mode, it has always been a minor mode of knowledge acquisition in our evolutionary
history. In the west, however, the didactic mode of teaching and learning has come to prevail in our
schools to such an extent that it is often taken for granted as the most natural, as well as the most
efficacious and efficient way of going about teaching and learning. This view is held despite the many
instances in our own culture of learning through observation and imitation.
While there are many instances where the distinction between these two modes of learning is not easy to
delineate, there are nevertheless a number of general characteristics and differences that are readily
apparent and that are of significance for understanding why the apprenticeship mode of learning is so
powerful.
5.2. Characteristics of the apprenticeship mode
5.2.1. Apprenticeship as a way of life. The first of these differences is that apprenticeship happens as a
way of, and in the course of, daily life. It may not be recognized as a teaching effort at all. A Maya girl who
eventually becomes a midwife most likely has a mother or grandmother who is a midwife, since midwifery
is handed down in family lines. Doña Juana’s mother, for example, was a midwife. In one of the isolated
hamlets of Yucatan where I conducted interviews, all three midwives came from the same family, a family
that had produced famous midwives and shamans ever since anyone could remember [17].
Girls in such families, without being identified as apprentice midwives, absorb the essence of midwifery
practice as well as specific knowledge about many procedures, simply in the process of growing up. They
know what the life of a midwife is like (for example, that she needs to go out at all hours of the day or
night), what kinds of stories the women and men who come to consult her tell, what kinds of herbs and
other remedies need to be collected, and the like. As young children they might be sitting quietly in a
corner as their mother administers a prenatal massage; they would hear stories of difficult cases, of
miraculous outcomes, and the like. As they grow older, they may be passing messages, running errands,
getting needed supplies. A young girl might be present as her mother stops for a postpartum visit after the
daily shopping trip to the market.
Eventually, after she has had a child herself, she might come along to a birth, perhaps because her ailing
grandmother needs someone to walk with, and thus find herself doing for the woman in labor what other
women had done for her when she gave birth; that is, she may take a turn with the other women in the hut
at supporting the laboring woman, holding her on her lap, breathing and pushing with her. After the baby
is born, she may help with the clean-up and if the midwife doesn’t have time to look in on mother and
baby, she may do so and report on their condition. Eventually, she may even administer prenatal
massages to selected clients. At some point, she may decide that she actually wants to do this kind of
work. She then pays more attention, but only rarely does she ask questions. Her mentor sees their associJordan: Cosmopolitical Obstetrics
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ation primarily as one that is of some use to her (“Rosa already knows how to do a massage, so I can
send her if I am too busy”). As time goes on, the apprentice takes over more and more of the work load,
starting with the routine and tedious parts, and ending with what is in Yucatan the culturally most
significant, the birth of the placenta [18].
Thus, in the apprenticeship model of learning about midwifery, or pottery, or tailoring as described by Jean
Lave [19], there is likely to be almost no separation between the activities of daily living and the learning of
‘professional’ skills. Much of what the “apprentice” does (and I put the term in quotation marks because, at
the time, he or she may not be seen as an apprentice at all), has to do with growing up in a particular
environment. If your mother is a midwife, you are likely to know a lot about midwifery; if your grandmother
is a potter, you are likely to know something about making pots; and if you spend most of your childhood
in a tailor shop, you are likely to know a lot about what tailors do.
The activities of these child apprentices are often difficult to differentiate from play, in particular since in
traditional societies children tend to play at serious work. A ‘play tamale’ may not be a perfect tamale but it
is edible nevertheless and thus has some use value rather than being a purely pedagogical artifact. In
societies where apprenticeship learning is the routine unmarked way of knowledge acquisition, it is also
the case that there is little differentiation between work and play. Children, and old people, do partial or
somewhat defective jobs which are, however, appreciated for whatever use value they may have. This
use value is keenly appreciated both by children and by adults, and children will generally, on their own,
prefer activities that have societal value. Thus children in Yucatan prefer taking care of real babies to
playing with dolls. They will take delight in (sort of) plucking (most of) the feathers from a turkey, knowing
that while this is not a perfect job, it is a step towards getting the turkey into the pot. Even where
apprenticeship is a more formal affair, it preserves many of these characteristics. For example, Lave, in
her study of Liberian tailors, describes how boys are taken into tailor shops as apprentices at a young age
and thereafter spend most of their waking hours in the environment of the shops. She observes, that
“much learning looks like play”. I would add that it probably is also experienced as such. Or maybe more
correctly, our western distinction between learning as an activity in its own right and playing does not
prevail. Rather, the ‘apprentice’ is exposed to a certain environment, participates in sets of activities,
handles (plays with) certain kinds of artifacts and is entrained into the sphere of specialist work the same
way a child is into the home environment.
By contrast, didactic activities are specially marked. They occur at specific times and in particular places
and are discontinuous with the routine activities of daily life.
5.2.2. ‘Work’ as the driving force. In an apprenticeship situation, the activities in which masters and
students engage are driven by the requirements of the work to be accomplished, e.g. pots need to be
fired, a baby needs to be birthed, trousers need to be manufactured. The activities to which the apprentice
is a witness and, by stages, a contributor, are organized around work to be done, and whatever teaching
or learning may happen is coincidental to that overriding concern. As a consequence,. the progressive
mastering of tasks by the apprentice is appreciated, in its doing, not so much as a step towards a distant,
symbolic goal such as a certificate, but for its immediate use value. Lave says that the master of a tailor
shop who takes on an apprentice, “mainly intends to provide himself with help on a variety of errands and
small sewing tasks”. Similarly, in the case of a potter sitting at her wheel who asks her granddaughter to
bring her another lump of clay, weighs it in her hand, and rejects it as too dry, one could say that she has
taught the little girl how clay feels when it will not do for the job at hand. But from the potter’s point of view,
she has merely saved herself the effort of getting up and searching for the right clay herself.
Girls and young women in midwives’ households are recruited into midwifery work precisely in this
manner. The assistance they lend and the skills they learn by lending that assistance are in no way
different from the ways in which they might learn to prepare a chicken, thatch a roof, weave a hammock,
or say the words accompanying a ‘limpia’ (ritual cleansing). It is actually quite late in the process of
acquiring relevant knowledge and skills that a girl or young woman would be seen as a potential future
midwife, and quite often this does not happen until she is beyond middle age. The important point is that
the boys and girls whom we might, from our outsiders’ (and usually retrospective) point of view, identify as
‘apprentices’ are not so much ‘practicing for the real thing’ as doing useful and necessary tasks.
A major difference between didactic and apprenticeship learning, then, is that the first is driven by
pedagogic interests while the latter, more often than not, is driven by requirements of the work.
5.2.3. The temporal ordering of skill acquisition. Apprentice midwives, as we have seen, acquire
competence stepwise, starting with skills that are relatively easy and peripheral and where potential
mistakes have minimal costs. Lave points out that the components of the production sequence which
young tailor apprentices first experiment with are the ones which are least costly in terms of wasted
materials. The apprentice’s first assignment is sewing a garment from pieces someone else has cut, not
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constructing it from start to finish. Only when the individual production processes are mastered is the
entire production sequence put together. Similarly, among Zinacanteco Indian weavers, major chunks of
the garment construction process (e.g. dyeing, spinning, weaving, sewing) are learned in an order which
reflects economic concerns, i.e. the relative cost of novice errors, rather than the standard order of
production [20].
In Yucatecan childbirth, cost factors include such considerations as ritual and physical risk. Within the
entire birth sequence, from prenatal visits through the ceremony of massage-and-binding on the twentieth
postpartum day, birth attendance and placenta attendance are the last part of the sequence to be taken
over by the apprentice since they are most costly in terms of risk. I have reason to believe that parts of the
sequence which are symbolically particularly salient, as for example the bath of the newborn, would also
be deferred [21].
The learning sequence in the apprenticeship mode is thus not isomorphic with what Lave calls ‘the
production schedule’. The apprentice doesn’t learn something in a predetermined sequence from beginning to end. Rather, she learns a bit here and a bit there, all the time able to fall back on the expert, and
little by little becomes competent in ever increasing stretches of the production schedule. Only at some
advanced stage is she required to put the whole sequence together.
This process of working from the periphery of a task complex to the center stands in contrast to the ways
in which knowledge is ‘transferred’ in training sessions. There we find no ordering from peripheral to
central [22], from simple to complex, from inexpensive to costly. Rather, there is a (chrono)logically
ordered sequence, each component of which carries the same salience and must be acquired in a linear
order.
5.2.4. Bodily performance and embodied knowledge. While learning under the didactic model is
concerned with verbal and abstract knowledge, apprenticeship learning is, above all, the acquisition of
bodily skills. It involves the ability to do rather than the ability to talk about something, and indeed it may
be impossible to elicit from people operating in this mode what they know (how to do). To master the skill
means to acquire expert body behavior. Hence, talk, and particularly instructive talk, plays a minor role in
apprenticeship learning. The work done by talk is much more an expressive accompaniment: punctuating,
and in rhythm with, the bodily performance.
In my observations of apprenticeship learning the expert rarely provides didactic interludes. The midwife is
less likely to talk than to guide the hands. In learning how to do external version I found that I could not
expect the midwife to tell me what to do. Instead, her hands would rest on mine as I attempted to
duplicate the manipulation I had so often observed. I would slowly increase the pressure on the baby’s
head and rump, encouraged by her hands pressing on mine, until I felt her let up and reverse the direction
of pressure. This is how I learned what is ‘too much force’. In a real sense, the knowledge is in the hands
and transferred by the hands. It is truly embodied knowledge.
Talk in such an enterprise is coincidental to the activity. I did ask the midwife to tell me when I pressed too
hard, but she would communicate with me through her hands. This is not to say that we worked in silence.
Rather, there was typically a steady stream of talk, but as Doña Juana’s skillful hands went through their
routine, the conversation usually would be concerned with everyday topics such as the price of oranges,
who had come to visit, an impending fiesta, and the like. Only rarely did her work become the subject of
talk. But even then it was always tied to accompanying bodily demonstrations. For example, while
performing an external cephalic version she might explain such things as how she could tell the baby’s
head from the breech, but she would do that by showing how she felt the fetal parts with her hands.
Furthermore, she would invite the women present to also feel the difference [23].
We see, then, that in the apprenticeship mode the acquisition of bodily skills is primary, while the
verbalization of general principles is secondary, ill-developed and not well rehearsed. This lack of facile
verbal articulation is often mistaken as ignorance by people schooled in the didactic mode where talk is
primary and where the major problem is the converse, the translation of verbal knowledge into skillfull
behavior. We might say, then, that the apprenticeship mode is good for learning how to do something, the
didactic mode for learning how to talk about doing something.
5.2.5. Standards of performance and evaluation of competence. In the apprenticeship mode,
evaluation of the learner’s competence is implicit rather than explicit, and coterminous with the work being
accomplished rather than occurring as a specially marked event, i.e. a test. Standards of performance,
which in the didactic model are abstract and externally imposed, here are readily available in the work
environment, so that what constitutes masterful execution of a task is obvious.
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As the apprentice is progressively socialized into a collaborative work group, her most pressing concerns
are less with ‘learning X’ than with fitting into a complex social scene; that is, demonstrating appropriate
behavioral, interactional and linguistic skills that make her an unremarkable member of the group. For
example, accompanying the midwife on her rounds she not only carries the midwifery kit for her as a
younger person would for an older one, but she also learns to follow cues regarding when to open it, when
to tell what kinds of stories, where to sit during the massage, what kinds of touching to engage in, and so
on. Operating in an environment of competently executed tasks, the apprentice always knows just how
she is doing, how she measures up. In such situations, the standards for appropriate performance are
ever-present in the expert’s actions.
Given that the interaction is driven by the work to be accomplished rather than by anyone’s pedagogic
interests, little is said about the apprentice’s performance; in particular, praise and blame are unnecessary
since, in the work environment, the success or failure of the task performed is obvious and needs no
commentary. To a large extent, the evaluator is the learner herself rather than the expert.
It is also not necessarily a function of the master to pass judgment which certifies the apprentice as ready
to go on to the next step in the learning sequence. The apprentice, having observed the work sequence
many times, knows what remains to be learned. Moving on to the acquisition of the next skill may be up to
her and largely under her own direction. We have seen that an apprentice midwife masters a series of
skills piecemeal, as she is ready and as opportunities present themselves or are engineered by the older
midwife. At the same time, the skill learned is seen and appreciated for its role in the entire performance
chain. The exact course and pace of her movement through the problem region and associated task
space is much more under her own control than in a didactic situation, a notion which Lave refers to as
‘owning the problem’.
5.2.6. Invisible teaching, invisible teachers. There is a curious phenomenon in apprenticeship learning:
it looks like there is little teaching going on. Though in Yucatan the women of the community clearly and
demonstrably saw me as an apprentice midwife, and though I actually did learn many of the skills of a
midwife, I find it difficult to specify exactly how I was taught. Teaching simply did not occur as an
identifiable activity, and whatever instruction I received originated not from a teacher doing teaching but
from a midwife doing her work. This observation, namely that the apprentice’s master/teacher is much
less present in the learning situation than the didactic student’s lecturer/teacher, was also made by Lave
who had difficulty observing learning and teaching actually in progress. In the tailor shops, most apprentices knew how to make trousers and were busy doing it. Yet no one seemed to be teaching them.
It appears, then, that for the apprentice there are many possible sources of knowledge and many occasions for practicing skills, some of which are independent of the mentor’s presence. Lave notes that “the
master’s involvement is necessary, but in practice is only a small part of the various sources of knowledge
available to the apprentice”. And “For the most part, model building and practice techniques are acquired
by the apprentice without active intervention from teacher figures.”
That we find the master’s comparative absence remarkable at all is probably due to our deeply ingrained
western assumption that without teaching there is unlikely to be learning [24]. As Lave points out, this
premise has probably informed, and biased, much research on learning. For example, in Zinacantan,
videotaped sessions were organized by the researchers on the assumption that teachers must be major
actors in the learning process. Thus the research procedures may have created the impression of more
teacher involvement than might have been the case in everyday weaving.
A major feature of apprenticeship learning, then, is that knowledge acquisition occurs, for the most part,
without active teacher intervention; apprenticeship learning is coincidental rather than teacher-driven. I
suspect that this feature will turn out to be central to our understanding of the differences between apprenticeship and didactic learning.
5.2.7. The role of stories. Another issue which requires further research is the role of stories in
apprenticeship learning. There are three central observations: the first is that requests for abstract and
hypothetical formulations produce stories; the second is that stories play a major role in decision-making;
and the third shows that stories function to legitimate the practitioner.
One of my initial frustrations in working with midwives was that it was almost impossible to get them to talk
about how they would handle cases other than the ones we were engaged in dealing with at just that time.
I had a long list of questions about low-frequency occurrences which I was unlikely ever to observe, such
as postpartum bleeding, still-born babies, cases of eclampsia, twins, breech births, and the like. It was first
of all difficult to get them focused on such questions; most generally, I would get agreement that yes, that
is something that can happen; or the ubiquitous: ‘pues, quien sabe’ (who knows). If I insisted and pushed
enough, I would invariably get a story about a particular case, often one that was linked to the present
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situation. For example, I vividly remember asking a village midwife about the possibility of a ruptured
uterus. She was vague and evasive until, on our walk, we passed a particular house. She then told me the
story of a woman, living in that house, who had almost died because she had been given injections of
oxytocin after which, it was said, her uterus ruptured. On other occasions, the story was linked to the
present through such devices as kin links (“The sister of Maria, you know the one we visited yesterday,
when she was having her third child. . .”)
Most impressive, however, is the way in which stories function in decision-making during actual labors.
What happens is that as difficulties of one kind or another develop, stories of similar cases are offered up
by the attendants, all of whom, it should be remembered, are experts, having themselves given birth. In
the ways in which these stories are treated, elaborated, ignored, taken up, characterized as typical and so
on, the collaborative work of deciding on the present case is done. When a woman is making little
progress in her labor, one of her attendants may tell the story of one of her own births where she had
similar trouble and solved it by moving from her hammock to a chair. Others may agree, or tell stories of a
different sort, for example, how in the labor of some other woman spoonfuls of a special honey (from
indigenous bees) solved the problem. These stories, then, are packages of situated knowledge,
knowledge that is not available abstractly, but is called up as the characteristics of the situation require it.
To acquire a store of appropriate stories and, even more importantly, to know what are appropriate
occasions for telling them, is then part of what it means to become a midwife [25].
In addition to this information-packaging function, some stories also serve as culturally recognized claims
to expert status. There are certain stories the apprentice needs to learn to tell in order to be recognized as
a bona fide member of a community of practitioners. Such stories may be quite stereotyped. For example,
Lave reports that “every tailor who described his apprenticeship included an account of the day his master
left the shop in the middle of sewing a pair of trousers for a customer and told him to finish it”. In Yucatan
today, midwives tend to tell stories about training they have had with western medical personnel while
traditionally—and this is still the case in remote hamlets—midwives told about dreams during which they
received their calling and learned everything they know from ‘goddesses’ (diosas). This, incidentally,
makes evident that how people learn may differ in important ways from their stories of how they learn.
What seems clear, however, is that learning to become an expert practitioner means not only learning
how to perform certain sets of instrumental actions but also learning how to tell certain kinds of stories.
6. CONCLUSIONS: COSMOPOLITICS
Training courses, as we have seen, promulgate as authoritative the views of cosmopolitan obstetrics.
They propose and enforce a ‘progressive’ and medicalized discourse that makes indigenous ways of
seeing, talking about, and being in the world unmentionable, invisible and irrelevant. In treating western
obstetrics as the only kind of legitimate knowledge, they not only devalue indigenous ethno-obstetric
wisdom and skills, they disallow the very methods of indigenous knowledge and skill acquisition.
Official training sessions, in the process of transmitting officially certified knowledge, transmitting it and not
something else, such as, for example, a woman-centered view or a low-technology approach to birth,
render midwives’ praxis and discourse deficient and without import. By the fact that midwives’ knowledge
is not transmitted in such official sessions, by the fact that apprenticeship is not an official teaching and
learning method, the indigenous approach is rendered invisible and marked as without status, while
cosmopolitan obstetrics emerges as the only system of legitimate authoritative knowledge. In this way,
cosmopolitan obstetrics becomes a cosmopolitical obstetrics, that is to say, a system which enforces a
particular distribution of power across cultural and social divisions.
Ten years ago there was so little anthropological research about birth that the superiority of biomedicine
and its associated pedagogy could still be assumed; by now, the work of the last decade has produced a
deep scholarly appreciation of ethno-obstetric systems of knowledge and practice [26] which, however,
has not yet entered into the design of training programs to any great extent. What has been taken into
account even less is the mode of knowledge transfer on which indigenous obstetric systems have relied in
their own reproduction.
The introduction, if not to say the imposition, of didactic formal pedagogy must be appreciated for its
transformational political effects. As the French anthropologist Pierre Bourdieu has pointed out:
[Formal schooling] succeeds in obtaining from the dominated classes a
recognition of legitimate knowledge and know-how (e.g. in law, medicine,
technology, entertainment or art), entailing the devaluation of the knowledge and
know-how they effectively command (e.g. customary law, home medicine, craft
techniques, folk art and language, and all the lore handed on in the hedge-school
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of the witch and the shepherd...) and so providing a market for material and
especially symbolic products of which the means of production are virtually
monopolized by the dominant classes (e.g. clinical diagnosis, legal advice, the
culture industry, etc.) [27].
I would suggest that if we want to understand where our pedagogy fails, we need to take seriously the
knowledge that is passed down ‘in the hedge-school of the midwife’ and other practitioners of this ‘lowly’
kind.
Acknowledgements—My interest in these issues was initially stimulated by the draft of a paper by
Collins, Brown and Newman [28] and by Jean Lave’s writings on apprenticeship learning in Liberian tailor
shops. I am indebted to Nancy Fuller and Mary Elmendorf, my colleagues during fieldwork in Yucatan, for
many of the observations discussed here. I also thank John Seely Brown, Allan Collins, Rita Gallin,
Veronica Gioia, Austin Henderson, Susan Irwin, Susan Newman, Cati Pelissier, Ronald C. Simons, Lucy
Suchman, Randy Trigg, Luis Alberto Vargas and several anonymous reviewers for their comments. I owe
a special debt to Jean Lave for extended discussion and contributions to my current thinking on this topic.
The anthropological fieldwork on which this paper draws was made possible by grant No. HD MH 115711
from the National Institute for Child Health and Human Development; my participation in midwife training
courses was supported by the U.S. Public Health Association under a contract with USAID and by the
Research Institute for the Study of Man, New York. An earlier version of these materials appeared as
Learning by Doing: Lessons I Learned from Traditional Midwives, Women in International Development
Working Papers No. 169, East Lansing, Mich.: Women in International Development Office, Michigan
State University, 1988; and as Modes of Teaching and Learning: Questions Raised by the Training of
Traditional Birth Attendants, IRL Technical Report, No. 004, Institute for Research on Learning, Palo Alto,
Calif. 1987. The support of the Institute for my thinking and writing in this area is gratefully acknowledged.
REFERENCES
1.
The debate over this dual agenda of developmental efforts has been particularly intense in the
area of primary health care. Cf. Heggenhougen H. K. Will primary health care efforts be allowed to
succeed? Soc. Sci. Med. 19, 217, 1984; Lee R. P. L. Comparative studies of health care systems. Soc.
Sci. Med. 14B, 191, 1982; McEvers N. C. Health and the assault on poverty in low income countries. Soc.
Sci. Med. 14C, 41, 1980; Navarro V. A critique of the ideological and political positions of the Willy Brandt
Report and the WHO Alma Ata Declaration. Soc. Sci. Med. 18, 467, 1984; Werner D. and Bower B.
Helping Health Workers Learn. The Hesperian Foundation, Palo Alto, Calif., 1982; World Health
Organization Primary Health Care. International Conference on Primary Health Care, Alma-Ata, U.S.S.R.
6 - 12 September, 1978. A joint report by the Director-General of the World Health Organization and the
Executive Director of the United Nations Children’s Fund 1978; Formulating Strategies for Health for All by
the Year 2000. Document of the Executive Board of the World Health Organization, 1979; Global Strategy
for Health for All by the Year 2000. Health for All Series No. 3. WHO, Geneva, 1981. For the notion of a
‘cosmopolitical obstetrics’ I am indebted to Pfleiderer B. and Bichman W. Krankheit und Kultur: Eine
Einfuehrung in die Ethnomedizin. Dietrich Reimer, Berlin, 1985.
2.
Following a suggestion by Carol MacCormack, I mostly refer to the midwives as ‘traditional
midwives’ or ‘village midwives’, avoiding the term ‘traditional birth attendants’ or ‘TBAs’ except in the
context of training courses. Some of the sources that discuss difficulties in TBA training are: Claquin P. et
al. An Evaluation of the Government Training Programme of Traditional Birth Attendants. International
Centre for Diarrhoeal Disease Research, Special Publication No. 18, Dacca, Bangladesh, 1982.
Greenberg C. Midwife training programs in Highland Guatemala. Soc. Sci. Med. 16, 217, 1982. Jordan B.
and Pelissier C. Training courses for traditional birth attendants: notes on pedagogy. Paper presented at
the National Meetings of the American Association for Social Anthropology in Oceania, Symposium on
Schooling and the Transformation of Pacific Society, Savannah, Ga, 18 February, 1988. Mangay
Maglacas A. and Pizurki H. (Eds). The Traditional Birth Attendant in Seven Countries: Case Studies in
Utilization and Training. WHO Public Health Papers No. 75, Geneva, 1981. Nicholas D. D. et al. Attitudes
and practices of traditional, birth attendants in rural Ghana: implications for training in Africa. Bull. Wld Hlth
Org. 54, 343, 1976. Pfleiderer B. and Bichman W. Krankheit und Kultur: Eine Einfuehrung in die
Ethnomedizin. Dietrich Reimer, Berlin, 1985. Pillsbury B. Policy and evaluation perspectives on traditional
health practitioners in national health care systems. Soc. Sci. Med. 16, 1825, 1982. Population Reports.
Traditional Midwives and Family Planning. Series J, No. 22, 1980, Sich D. Mutterschaft und Geburt im
Kulturwandel. Verlag Peter Lang, Frankfurt am Main, 1982. Traditional Birth Attendants: A Field Guide to
Their Training, Evaluation, and Articulation with Health Services. Offset Publication No. 44. WHO,
Geneva. Traditional Birth Attendants: An Annotated Bibliography on Their Training, Utilization and
Evaluation and 1981 supplement to same. HMD/NUR/79.1 and HMD/NUR/81.l WHO, Geneva (Division of
Health Manpower Development), 1979 and 1981. The Potential of the Traditional Birth Attendant. A.
Jordan: Cosmopolitical Obstetrics
page-14
Mangay Maglacas and John Simons, eds. WHO Offset Publication No. 95: WHO (Division of Manpower
Developments,) Geneva 1986.
3.
Jordan B. Birth in Four Cultures: A Crosscultural Investigation of Childbirth in Yucatan, Holland,
Sweden and the United States. 3rd edn. Eden Press, Montreal, 1983.
4.
These kits contain simple implements and supplies useful for attending home births, such as
scissors, steel bowls, sterile umbilical ties, a rubber syringe for suctioning mucus, a brush for
handwashing, soap, a plastic apron, plastic sheeting, alcohol, eye drops for the newborn, and the like.
5.
A set of graffiti collected at a midwestern university captures the essence of such conventions
nicely. The first reads: “To draw is to leave things out”. The next day’s addition: “To draw well is to know
what to put in”.
6.
Development workers routinely point out that verbal instruction has little impact on actual
behavior, though it may well produce new ways of talking. For example, Debra Rothenberg, discussing
evidence of rote memorization from Niger, writes: “I vividly recall one of the older matrons [native
midwives] marking a line in the sand for each sign of malnutrition she cited as her two year old grandson
stood by with wrinkled, wasted buttocks. Obviously the ability to repeat the lessons does not reflect
assimilated understanding of the concepts” (Primary health care and the role of traditional midwives in
Niger. Unpublished manuscript, 1985).
7.
Jordan B. External cephalic version as an alternative to breech delivery and cesarean section.
Soc. Sci. Med. 18, 637, 1984. High technology: the case of Obstetrics. Wld Hlth Forum 8, 3,312, 1987.
8.
Cf. Lave J. Experiments, tests, jobs and chores: how we know what we do. In Becoming a
Worker (Edited by Barman K. and Reisman J.). Ablex, Norwood, N.J., 1987.
9.
Sosa R. et al. The effect of a supportive companion on perinatal problems, length of labor, and
mother-infant interaction. New EngI. .1. Med. 303, 597, 1980.
10.
The pulsating they feel under the navel is the abdominal aorta in our biomedical explanatory
system. See also Villa Rojas A. Las imagines del cuerpo humano segun los Mayas de Yucatan. Anal.
Antrop. 17, 31, 1980.
11.
Fuller N. and Jordan B. Maya women and the end of the birthing period: postpartum massageand-binding in Yucatan, Mexico. Med. Anthrop. 5, 35, 1981.
12.
As in many developing countries, oxytocin can be purchased in injectable form in pharmacies in
rural towns.
13.
A few of the supernatural beliefs and cautions which Yucatecan women adhere to around birth
are described in [3]. An excellent discussion of the supernatural calling of Maya midwives in a culturally
closely related area, the highlands of Guatemala, can be found in Paul L. Careers of midwives in a Mayan
community. In Women in Ritual and Symbolic Roles (Edited by Hoch-Smith J. and Spring A.). Plenum
Press, New York, 1978.
14.
McClain C. Traditional midwives and family planning: an assessment of programs and
suggestions for the future. Med. Anthrop. 5, 107, 1981.
15.
Poirier F. E. and Hussey L. K. Nonhuman primate learning: the importance of learning from an
evolutionary perspective. Anthrop. Educ. Q. 13, 133, 1982.
16.
This is clearly part of our primate heritage. Most nonhuman primate learning is observational and
occurs during play [15].
17.
These interviews were conducted together with anthropologist Mary Elmendorf who was, at the
time, investigating reproductive knowledge and practices in the’ village of Chan Kom.
18.
For a description of the Yucatecan birth sequence see [3] and [11].
19.
In what follows I rely very heavily on Jean Lave’s unpublished manuscript on apprenticeship
among tailors in Liberia. Tailored learning: apprenticeship and everyday practice among craftsmen in
West Africa. All references are to his manuscript unless otherwise indicated.
Jordan: Cosmopolitical Obstetrics
page-15
20.
Greenfield P. M. and Childs C. P. Weaving, color terms, and pattern representation: cultural
influences and cognitive development among the Zinacantecos of southern Mexico. Interam. J. Psychol.
11, 23, 1977.
21.
One wonders how such issues are handled in other ‘shop environments’. For example, what was
the involvement of master painters during the Renaissance in the production of the works turned out by
their ateliers? Were there certain parts of the painting reserved for the master? Or did he lay out the
design? Cf. Chicago’s J. The Birth Project. Doubleday, Garden City, N.Y. 1985.
22.
Hutchins E. Learning to navigate in context. In Situation, Occasion, and Context in Activity
(Edited by Chaiklin S. and Lave J.). Cambridge University Press. In press.
23.
Actual experience in palpating the fetus may be the reason why some women insisted that the
breech is larger than the head since this is what it feels like when one palpates the fetus in utero. We think
of the head as the largest part since we judge it as it goes through the birth canal at the time of birth when
the breech is compressible while the head is not. Cf. Jordan B. and Fuller N. Turning the baby (external
cephalic version). Video cassette.
24.
Werner D. and Bower B. Helping Health Workers Learn. The Hesperian Foundation, Palo Alto,
Calif., 1982.
25.
Cf. Julian Orr’s work on diagnostic narrative among ‘tech reps’ and Evelyn Early’s reports of
therapeutic narratives of Egyptian women. Orr J. E. Narratives at work: Story telling as cooperative
diagnostic activity. In Proceedings of the Conference on Computer-Supported Cooperative Work, Austin,
Tex., December 1986. Early E. A. The logic of well being: therapeutic narratives in Cairo, Egypt. Soc. Sci.
Med. 16, 1491, 1982.
26.
See ref. [3]. Kay M. (Ed.) Anthropology of Human Birth. Davis, Philadelphia, Penn., 1982.
MacCormack C. (Ed.) Ethnography of Fertility and Birth. Academic Press, New York, 1982.
Schiefenhoevel W. and Sich D. (Eds.) Die Geburt aus ethnomedizinischer Sicht. Friedrich
Vierweg, Curare Sonderband I. Braunschweig/Wiesbaden, 1983. Sich D. Mutterschaft und Geburt im
Kulturwandel. Peter Lang, Frankfurt am Main, 1982. WHO. Traditional Birth Practices: An Annotated Bibliography. WHO IMCH/85. 11. WHO (Division of Family Health), Geneva, 1982.
27.
Bourdieu P. and Passeron J.-C. Reproduction in Education, Society and Culture, p.42. Sage
Studies in Social and Educational Change, Vol. 5. Sage, London, 1977.
28.
Collins A., Brown J. S. and Newman S. E. Cognitive apprenticeship: teaching the craft of reading,
writing, and mathematics. In Cognition and Instruction: Issues and Agendas (Edited by Resnick L. B.).
Lawrence Erlbaum, Hillsdale, N.J., 1988.
COMMENTS
C. H. BROWNER
Department of Psychiatry and Biobehavorial Sciences, UCLA, Los Angeles, CA 90024, U.S.A.
Brigitte Jordan’s paper provides penetrating insight into why well-intentioned programs designed to ‘upgrade’ the skills of traditional birth attendants (TBA) and other local-level health care workers often fail to
achieve their stated goals. She demonstrates that the difficulties derive not simply from false assumptions
trainers make about local-level health care workers but, more importantly, from the instructional mode
favored for such training. The paper effectively characterizes the contrasting assumptions on which didactic and apprenticeship learning are based. Jordan shows that most midwives, and many other local-level
health care workers, acquire ‘authoritative’ knowledge through apprenticeship training. Yet because the
didactic mode predominates in formal instruction in industrial societies, this is the approach generally used
in TBA training. In contrast, the processes of apprenticeship learning have been poorly studied and
infrequently applied; they have been devalued as well.
Yet even in instructional settings where the didactic mode predominates, features of apprenticeship learning are also found. It has been suggested, for instance, that in industrialized societies, the purpose of
formal education is not to impart specific information (which is generally quickly forgotten by most students
and for which few have much future use), but rather to socialize students to be compliant, to follow instructions, and to value certain kinds of information and types of authority. In that sense, teachers in
Jordan: Cosmopolitical Obstetrics
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industrialized societies are role models to which students are ‘apprenticed’, not to learn concrete skills but
rather specific behaviors, attitudes and values. And this is why training programs such as those described
by Jordan are destined to fail. They fail not simply because their content is irrelevant (for that could
certainly be changed), but also because the behaviors, attitudes, and values that are imparted through
didactic instruction cannot be taught in a one-week program. Nor are the behaviors, attitudes and values
engendered through such didactic methods useful to midwives in their daily activities.
Jordan is thus correct when she argues that what midwives get from brief didactic training courses is a
way of ‘talking’ not a way of ‘doing’, for that is what didactic instruction is all about. Female birth attendants may therefore eagerly seek such training if they see it as a route to enhanced authority or prestige.
When women are excluded from their communities’ traditional sources of power, prestige and authority,
they may be drawn to training programs or change-oriented activities because they promise an alternate
route to recognition [1]. Whether they will be successful at forging an alternate status hierarchy depends,
of course, on local conditions. As Jordan accurately observes, didactic training often creates or reinforces
asymmetrical power relations, which may or may not be recognized at the local level.
Jordan is therefore not completely accurate when she argues that all midwives gain by participating in
government-sponsored training programs are a vocabulary and a way of talking about their work. I agree
that such ‘talk’ is unlikely to be transformed into behavior, but it may instead transfer into something less
tangible such as prestige or authority at home. Thus while some women who undergo didactic training
come to doubt their skills when told by ‘experts’ that their own expertise is lacking, others may acquire a
false sense of confidence simply because they have learned a new language.
While Jordan’s findings have broad applicability in many settings where social change efforts revolve
around the redefinition of authoritative knowledge, I wish to caution against overgeneralizing or overromanticizing the case: not all specialized learning in traditional societies makes use of the apprenticeship
mode. In the indigenous Mexican community where I worked, some healers were trained didactically by
more experienced curanderos and most midwives were self-taught. Neither group experienced an extended period of apprenticeship training.
REFERENCE
1.
1986.
Browner C. H. Gender roles and social change: a Mexican case study. Ethnology 25, 89—106,
THE EMPTY KIT: MODALITIES OF LEARNING AND THE
POLITICS OF CROSS-CULTURAL MISCOMMUNICATION
Robert A. Hahn
Department of Anthropology, Emory University, Atlanta, CA 30322, U.S.A.
In her insightful anthropological examination of the ‘upgrading’ of traditional birth attendants (TBAs) in
Mexico, Brigitte Jordan reveals how the social organization of intercultural exchange not only fails to
promote a fruitful transfer of knowledge and technique, but instead affirms the ideologies and statuses of
participants on both sides of the cultural divide, reinforcing mutual misperceptions. Two features of the
training course for TBAs make effective transfer unlikely:
1.
Training program designers assume that knowledge and technique appropriately flow in one
direction only, from biomedical trainer to TBA. They assume that their biomedical principles of obstetrical
care are universally applicable, that biomedical practitioners could learn nothing of use for themselves
from the TBAs, and finally that they need not understand the beliefs and practices of the TBAs in order to
instruct them.
2.
Trainers do not make use of the traditional modes of TBA learning, namely apprenticeship. They
assume that their own didactic methods of instruction are appropriate to impart the desired skills and
knowledge to TBAs. They lecture in classrooms, dissociated from the events they describe; they give
abstract definitions of concepts which are often irrelevant; they use western iconic forms (e.g. diagrams
and projected slides) not interpreted by TBAs as they are by the trainers; and they require note taking,
rote learning and verbal examinations.
The effects of this intercultural encounter are comical, tragic and paradoxical—symbolized by the graduation ceremony in which TBAs are photographed with empty obstetrical equipment kits to be returned
Jordan: Cosmopolitical Obstetrics
page-17
after the ceremony. From Jordan’s account, it appears that midwives have mislearned more of biomedical
obstetrical practice than they have learned. Some of what they have mislearned may be harmful, e.g.
insufficient sterilization and early use of pitocin. They leave with a sense that they are inadequate by
biomedical standards; yet their status in their communities is enhanced by having taken the course and by
employing some of the language of biomedicine, however inappropriately. For their part, the course instructors leave with written documentation that they have ‘upgraded’ provincial midwives in the required
information. In sum, while the statuses of all are enhanced, no one has learned anything of practical
value.
Jordan’s essay addresses two issues of fundamental importance: (I) differing modalities of learning appropriate to people in differing social conditions (e.g. ‘developed’ and ‘underdeveloped’), perhaps for different
sorts of skills and subject matters (e.g. riding a bicycle, delivering a baby and developing mathematical
theory), and (2) the knowledge and skills which people in differing social settings have to contribute to
each other, and the ways in which this exchange may be best achieved.
Several of Jordan’s remarks suggest that she regards three modes of learning—genetic, imitative (i.e.
apprenticeship), and didactic—as mutually exclusive. I believe them to be hierarchically inclusive, i.e. genetic arrangements provide a necessary basis for both imitative and didactic knowledge acquisition, though
genetic learning may occur in the absence of imitative or didactic forms (for example, when an animal
learns in isolation). Similarly, while imitative learning may occur without didactic learning, didactic learning
often includes learning by imitation. That is, from an instructor one may learn the instructor’s subject
matter, or, by imitation, how to instruct (or both, or neither). The TBAs, for example, learn some of the
vocabulary of biomedical talk in addition to a version of the biomedical world view to which this talk refers.
While official pedagogic theory in biomedicine proclaims the primacy of didactics in medical education,
medical students and practitioners commonly debunk much of the didactic subject matter as practically
useless, suggesting that true learning of medicine begins on the ward and by the bedside. Physicians in
training on ‘rounds’ not only learn the medical treatment of patients, but medical rhetoric and medical
behavior as well. Didactics is the explicit method and the implicit subject of this training.
It is likely that the members of different societies, particularly in the ‘developed’ and ‘underdeveloped’
worlds, have much to learn from each other. Jordan’s paper suggests that fruitful exchange is not likely if
the social and cultural nature of the exchange are ignored. TBAs must be recognized to be members of a
cultural tradition with a worldview and customary forms of communication and other interaction. Trainers
are more likely to succeed if they recognize and respond to this worldview, and if they engage in locally
established forms of communication. Perhaps they could usefully accompany TBAs in their rounds, to
learn TBA interactions and technique, and then to add their own techniques, in context. In fuller
engagement, they might also come to appreciate the others’ world.
R. JEFFERY and P. M. JEFFERY
Department of Sociology, University of Edinburgh, Edinburgh EH8 9LN, Scotland
This is an excellent discussion of how government training schemes fail, which has relevance far beyond
the Guatemalan, or even the Latin American situation. Our own research in North India, and work in the
training of health workers in eastern India, has provided many instances of similar teaching practices and
assumptions [1]. Ever since the publication in 1975 of Health by the People, traditional birth attendants
(TBA) have been trained in very similar ways in many parts of the world, with little evidence of success,
and Professor Jordan’s article makes it very clear why: the courses are badly organized, and based on the
wrong educational practices. The more general principles behind this argument are well expressed in F.
R. Abbatt and R. McMahon’s book [2]. Even in their own terms, these courses are so badly taught that
the questions for investigation must become, ‘Why do governments and donor agencies persist in wasting
their money in this way?’ and ‘What can be done that would make a worthwhile difference?’ In these
terms, while we heartily welcome its publication in Social Science and Medicine, we hope that its message
can be spread by many other channels of communication; though it seems unlikely that it will ever be
heeded by the unfortunates charged with teaching TBAs and village level health workers.
REFERENCES
1.
Jeffery P. M., Jeffery R. and Lyon A. Labour Pains and Labour Power. Zed Press, London, 1988.
2.
Abbatt F. R. and McMahon R. Teaching Health-Care Workers: A Practical Guide. Macmillan,
London, 1985.
Jordan: Cosmopolitical Obstetrics
page-18
UPGRADING APPRENTICESHIP
JEAN LAVE
Institute for Research on Learning, 3333 Coyote Hill Road, Palo Alto, CA 94304, U.S.A.
Jordan raises important issues about the mode of penetration of cosmopolitan biomedical practices in
third world countries. This is a powerful critique, the more so because her impressive field research over
almost a decade in Yucatan, permits her to contrast the methods used to educate midwives through a
process of apprenticeship with what happens to them in didactic training courses. Jordan’s analysis of the
effects of training courses (more political than technical, mostly perverse) is captured for me in the
powerful image of the midwives, new alumni of a training course in cosmopolitan obstetrics, photographed
in an official line, holding empty, fake United Nation’s midwifery kits. Her analysis of apprentice learning
suggests that its power lies in its integration into daily life, as it is embedded in work, as apprentices move
from peripheral to central tasks, and as they acquire embodied knowledge in a process they pace and
evaluate as they work.
Jordan also contrasts the role of language in apprenticeship learning and in didactic forms of knowledge
transmission. Indeed, a major stereotypic distinction between ‘formal’ (didactic) and ‘informal’ education
(including apprenticeship) typically focuses on language: schooling is said to be about the verbal
transmission of general knowledge (surely a view shared by the curriculum developers for the midwife
training courses as they arranged for lecture-format instruction and lessons on the definition of terms)
while embedded, inarticulate, intuitive learning by imitation should be characteristic of less formal educational forms. Jordan paints quite a different picture, beginning with the communication difficulties
created by the verbal approach of the training courses. Rather than imparting general, and hence
transportable, reuseable knowledge, the emphasis on verbal instruction at best teaches the midwives how
to talk in the language of biomedicine, not how to do something new or different. Its main effects are to
give facile reassurance to training personnel about their efficacy as teachers and a sort of defensive
legitimacy vis-à-vis the biomedical community to the midwives whose practices will never be seen by
training personnel. Didactic forms of knowledge transmission seem to be based on an illusion that
language provides a smooth tube through which knowledge is slipped to the learner, a one way, strongly
asymmetrical process; one which assumes the instructor’s task is to talk about basic knowledge. Turning
to apprenticeship, Jordan dispells the image of a silent or ‘grunt and point’ approach to practice. Learners
absorb basic processes in coincidental, peripheral, participation in the adept midwife’s practice. Talk plays
an intensely productive role in this practice, it may be noted, in collaborative diagnosis and decision
making about cases, most especially of difficult labor, through a process in which those attending births
produce stories about similar troubles and discuss the grounds for claiming similarity and gradually
determining the proper action to take.
In both didactic training courses and apprenticeship, learning to talk like a midwife is part of the process of
becoming part of a community of practitioners, but the two processes are strikingly different. I find this a
fascinatingly different and more complex view of language in learning than standard assumptions. The
emphasis on the collaborative character of typical forms of language use in apprentice learning and its
associated forms of specialized practice, as opposed to asymmetrical didactic ones, is a major
contribution of the paper. So is Jordan’s demonstration of the corresponding migration of typical forms of
skilled discourse from talk about basic background rules to talk about problematic and especially difficult
issues, and her insistence on the importance of the relation between the legitimacy of participation in
specialized practice and forms of language use.
Jordan suggests that the contrastive description of training and apprenticeship she has produced for
Yucatec midwives applies much more broadly in the propagation of biomedicine around the world. I would
like to address a slightly different question: to what extent is her description of Yucatec apprenticeship in
midwifery more broadly applicable to other forms of work? I can speak about at least one other case in
some detail, that of apprenticed Vai and Gola tailors in Liberia. To begin with, there are some notable
differences in the organization of apprenticeship in these two settings. Apprenticeship among the tailors
takes a more explicit form than among the midwives. It has a formal beginning and end, based on the
intention of the apprentice to become a master tailor; the apprentice becomes the ward of the master for
the duration. For the tailors, work shapes the day’s activity more than the other way around, the reverse
midwives’ apprenticeship. But apprenticeship learning for tailors as well as midwives involves embodied
knowledge, evaluation emerging in the process of carrying out the work, and very little explicit teaching. In
both cases all involved understand that apprentices are being socialized into a community of
practitioners—a more encompassing view than the notion that their goal is to acquire particular knowledge
or skill.
Jordan: Cosmopolitical Obstetrics
page-19
Thus, Jordan’s analysis of midwives’ apprenticeship captures what seem to be general and widespread
characteristics of such learning processes. She suggests as one further general characteristic of apprenticeship that the work to be done drives the organization of opportunities to learn. I agree with this
point at one level—learning-in-practice implies that it is ongoing work that provides the ‘curriculum for
learning’ and the pattern of opportunities to practice emerging skills. Jordan also makes a higher order
argument that I find more convincing than the initial claim about the work-ordered nature of learning. She
paints a strong contrast between didactic instruction as “the teaching of equally valued chronological
segments in linear order” and apprenticeship learning. Apprentice midwives understand the extent of the
corpus of work to be mastered very early in their learning careers. But they do not learn it in an order that
reproduces the process of carrying out that work. Instead, they learn its easy and peripheral tasks early
on, and the more risky (physical and ritual) aspects of the work later. This description of increasingly
central participation, which involves an increasing possibility of making costly errors, describes tailors’
apprenticeship as well. In such cases the structure of learning—moving from peripheral to central
participation in both the community and the work—cuts across the relations among segments of work far
more radically than many didactic procedures. And such a pattern of learning belies the notion that ‘work
drives learning’. Where instruction is removed from practice, so that the organization of the content
becomes the major single consideration guiding instructional practice, instruction might well be shaped by
the structure of that content far more than in apprenticeship.
I would like, finally, to explore the question of how general might be the troubles and effects of the training
courses beyond the setting of cross-cultural midwife training. Issues of legitimacy, asymmetrical
assumptions about who is knowledgeable and who ignorant are common to didactic educational situations
whether the cultural differences between learners and teachers are large or small. Jordan argues for the
generality of cultural ‘imperialism’ as a characteristic of didactic modes of knowledge transmission—it is
socialization into the (medical) profession that makes instructors blind to local culture, not the cultural
differentness of the midwives. Jordan distinguishes cosmopolitan from cosmopolitical obstetrics as
follows. The latter is a system which enforces a particular distribution of power across cultural and social
divisions. It is no distance at all from this description to the way in which educators conceive of the
‘everyday’ knowledge of the children whose nearly invisible knowledge they intend to replace.
In sum, this paper is a powerful, general account of learning as well as an eloquent critique of didactic
proselytizing and a window on little-understood processes of apprenticeship.
STATUS AND THE TRAINING OF TRADITIONAL
MIDWIVES
CAROL P. MACCORMACK
London School of Hygiene and Tropical Medicine, Keppel Street, London WCIE 7HT, England
Brigitte Jordan concludes her excellent monograph by noting that the last decade has produced a “deep
scholarly appreciation of ethno-obstetric systems of knowledge and practice”. She asks why this information has not yet entered into the design of training programmes for traditional midwives. One of the books
she cites at this juncture is Ethnography of Fertility and Birth. I edited this book, but when my scholarly
publications are listed by my academic department, it has been excluded on the grounds that it is not
relevant to the planning and evaluating of primary health care in developing countries [1]. At the very
centre of cosmopolitan medicine on behalf of the third world, where there is much teaching about maternal
and child health in a primary health care framework, ‘deep’ anthropological work is not seen as legitimate
knowledge [2]. Within medical schools the scientific paradigm remains narrow and buttresses a status
hierarchy which is unlikely to change. When anthropological description and analysis passes a certain
threshold beyond simplicity it is either not understood, or its professional competence may be glimpsed
and seen as a threat to the materialist quantitative faith of the medical profession.
Thus, we can expand Brigitte Jordan’s monograph from its conclusion. Bourdieu and Passeron [3] are
indeed correct in explaining how socially dominant groups attempt to confirm and reproduce their status
position by failing to recognize as legitimate the knowledge and skills of those who might challenge their
position. Within the primary health care structure of a developing country this challenge may be especially
threatening if junior doctors, nurses or maternal and child health aides are asked to train traditional
midwives. Their status position may be so insecure that one could not expect them to relinquish real skills
to traditional midwives, thus risking the possibility that village midwives might overtake them in social
esteem.
The conventional logic of traditional midwife training is that it must be done quickly and cheaply, therefore
it should be done through tiered training in which doctors train nurses, nurses train maternal health
Jordan: Cosmopolitical Obstetrics
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paramedicals, and they in turn train village midwives [4]. Thus, the poorly trained and poorly paid
paramedicals, who are often young and not particularly respected in the communities where they are
posted, are asked to teach women full of years, usually much respected in their community, and often
addressed in honorific terms. Predictably, the trainers will attempt to maintain status distance by using
expensive equipment which village midwives cannot afford, using esoteric language they cannot understand, boring them with abstract concepts while attempting to menace them with examinations, and
denying the legitimacy of their skills acquired through having assisted hundreds or thousands of births.
Looking at the problem sociologically, professionally secure doctors and senior district public health
nurses rather than nurses or lower-ranked paramedicals might be better trainers. Their status will not be
as threatened if village midwives do a good job. But looking at the problem culturally, doctors and perhaps
nurses may be too blinkered by the mechanistic medical paradigm they have been required to accept as
an article of faith before being confirmed in their professional status. Perhaps the best hope for enhancing
traditional midwives’ skills is in bypassing the medical and nursing professions and concentrating instead
on targeted literacy programmes so that such self-help books as David Werner’s Where There is No
Doctor [51 can become accessible to village women. Adept traditional midwives who might acquire
enhanced skills in this way may then pass on those skills to other midwives. We are beginning to realize
the extent of social contact that there is among traditional practitioners [6]. In Sierra Leone, traditional
midwives never work single-handed. One sees about four string beds for them in the house of the
women’s secret society where women give birth [7, 8]. They chat, provide relaxed social support for the
woman in labour and each other, and pass on skills, often through their hands, in the way Brigitte Jordan
describes for Mexico. The most successful co-operation between the traditional system and the national
health service in Sierra Leone occurred when insecure young paramedicals, on their own initiative,
teamed up with one or more traditional midwives in their area, working respectfully with them during births,
or in providing other health services.
Dr Tom Kargbo, Consultant Obstetrician in Sierra Leone, has written insightful descriptions of how his
countrywomen visualize their reproductive system and its function [9]. Many, for example, do not think of
the foetus in a uterine ‘bag’, but it is just in the belly. Therefore, traditional midwives may apply so much
fundal pressure as to rupture the uterus, not knowing that there is anything there to rupture.
Anthropologists have been inspired by such exceptional obstetricians and have brought their skills to bear,
for example, in developing projective methods for helping women describe and even draw this inner
geography. In Jamaica, as in Sierra Leone, some women visualized the vagina/womb as an open-ended
tube, and worry much about the foetus or placenta ‘rising’, and an IUD drifting about the body [10, 11].
These concepts must be explored in the way Brigitte Jordan described the tipté, acknowledged, and
discussed openly in maternal health initiatives, and in health worker training programmes.
There is another practical reason why many professional trainers teach in a way that maximizes status
distance between themselves and traditional midwives. They may not know important skills for enhancing
maternal health, such as how to do external version as a relatively low risk procedure, reserving the
surgical intervention of a caesarian section as a relatively high risk final option. Their professional
qualification does not depend on their being able to give comforting social support that relaxes a woman in
labour and helps her muscles work in harmony with the birth process. Often relaxing movements for
labouring women are known without reference to medicine, carried over from techniques village women
know for easing the burden of their agricultural labour, or even from dancing in a ritual context [12, 13].
Trainers with only schooling qualifications do not know how to steam and massage a woman in the postpartum period to promote lactation and enhance recovery of muscle tone [14]. They are not ritual
specialists and therefore cannot acknowledge that birth is a rite of passage that integrates mind, body and
spirit.
This diagnosis of problems in traditional midwife training programmes is drawn in general terms, but when
we look at some particular cases there is cause for cheer. Although some senior staff in medical school
may not be interested in a book such as Ethnography of Fertility and Birth, postgraduate students who are
mid-career physicians from developing countries, or have worked in developing countries, are. Many are
close to their cultural roots and have been posted as medical officers to remote parts of their country with
little professional back-up [15]. They know the humility we anthropologists know as we settle into an area
and are regarded—usually with kindness—as a promising child who cannot weave or make a fish trap but
might learn. As these isolated young doctors learn to work with human and material resources at hand,
and extend their social network, they grow in the kind of self-esteem that will later sustain them as they
challenge cosmopolitan medical orthodoxy.
I happened to be sitting in on the primary health care coordinating committee in The Gambia when Dr
Kabir Cham (now Medical Officer of Health for the whole country) suggested that since Honda motorbikes
for rural health workers were difficult to maintain perhaps pony carts which are widely used might be
better. The reaction was to laugh at this unmodern idea. He persisted and asked for a trial. He was given
Jordan: Cosmopolitical Obstetrics
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one cart, with such an old horse that it died in a month. He could laugh about bias in the sample and
continue in his efforts to find appropriate technologies to support primary health care. On another
occasion, when we were working with a team of -Gambians to understand why primary health care
worked well in some villages but not in others, we realized afresh how vulnerable in-marrying wives feel in
a multi-ethnic patrilineal patrilocal society. In childbirth they prefer, at a minimum, to be helped by a village
midwife of their own ethnic group. Following international guidelines, The Gambia had been training only
one of the set of 4 - 10 midwives commonly found in villages. Choosing only one contributed to village
factionalism by setting a woman of one lineage and ethnic group above others. Furthermore, many
women in labour did not go to the official TBA, preferring an ‘untrained’ midwife who was closer to them in
social terms. Realizing this, Dr Cham took the decision immediately to begin training all traditional
midwives in primary health care villages. He knew how little their training cost, what the health budget
would bear, and genuinely wanted to promote harmony and health in the villages of his country [16].
In Burma, Dr C. Kai Ming, an excellent epidemiologist, perhaps ‘demoted’ in the eyes of some
professionals to merely teaching in a paramedical school, has successfully reorganized training. He and
his humanitarian medical colleagues in Rangoon’s Health Assistant Training School have eliminated the
type of mind-numbing content and methods Brigitte Jordan describes, replacing them with task-based
training. What exactly are village midwives reasonably expected to do? Once those tasks are listed, then
the content and methods of practical training be-comes clear. Some on-the-job, in-the-village training
became an obvious requirement. One feels the joy and comradeship of those trained village women who
are instantly recognizable in their red lungis (wraparound skirt). Burma is a remarkable country in the
number of paramedical workers well trained for village work—many of them unpaid volunteers—and the
astonishingly low turn-over rate. The country has done so well on the quantity trained that they are now
turning their attention more directly to the quality of training and services. Village midwives are realistically
trained, supported by the national health service in areas under secure government control, and function
in a Buddhist society which acknowledges the blessings that accrue to those who serve others [17].
As Burma and other countries have discovered, paramedical training was easiest to reorient toward
practical task-based work, changing nurse training was just possible, and medical training often remains
encased in cosmopolitan medical orthodoxy. Ideally, all levels will transform and support each other in a
single system. In countries where all levels of the health service cannot function harmoniously to support
village midwives perhaps the only path to follow is the path directly to ‘people’s knowledge’ which David
Werner has blazed.
And what of anthropologists? We must persist in the humanitarian requirements of our discipline. Some
non-governmental agencies, and some national bilateral agencies—notably in Canada, The Netherlands
and Scandinavia—particularly seek anthropological collaboration. Among the less humanistically oriented
funding agencies, they will sometimes ask us to help evaluate a training programme which is in trouble
and we can point out yet again the type of things Brigitte Jordan has identified. Such agencies may not
want to waste their money on project after project and may even invite us in at the planning stage. We
must be firm on this point, and if we agree to do a post mortem on a useless programme, try to win an
agreement to be part of the team that plans the next traditional midwife programme, always working to
broaden its scope beyond the narrow manipulative medical paradigm.
REFERENCES
I.
Dr MacCormack is in the Evaluation and Planning Centre for Health Care of the London School
of Hygiene and Tropical Medicine.
2.
MacCormack C P. Health care and the concept of legitimacy. Soc. Sci. Med. ISB, 423—428,
1981.
3.
Bordieu P. and Passeron J. C. Reproduction in Education, Society and Culture. Sage, London,
1977.
4.
World Health Organization. Traditional birth Attendants: An Annotated Bibliography on their
Training, Utilization and Evaluation. WHO, Geneva, 1979.
5. Werner D. Where There Is No Doctor. Hesperian Foundation, Palo Alto, Calif., 1977.
6.
Ngubani H. The predicament of the sinister healer. In The Professionalisation of African Medicine
(Edited by Last M. and Chavunduka G.), pp. 189—204. University of Manchester Press, 1986,
7.
MacCormack C. P. Sande: the public face of a secret society. In The New Religions of Africa
(Edited by Jules-Rosette B.), pp. 27—38. Ablex Press, Norwood, N.J., 1979.
8.
MacCormack C. P. (Ed.) Ethnography of Fertility and Birth. Academic Press, London, 1982.
9.
Kargbo T. K. Traditional Midwifery Amongst the Mende of Southern Sierra Leone. Fourah Bay
College, Freetown, Mimeograph, 1975.
10.
MacCormack C. P. Lay concepts affecting utilization of family planning services in Jamaica. J.
trop. Med. Hyg. 88, 28 1—285, 1985.
11.
MacCormack C. P. and Draper A. Social and cognitive aspects of female sexuality in Jamaica. In
The Cultural Construction of Sexuality (Edited by Caplan P.), pp. 143—165. Tavistock, London, 1986.
Jordan: Cosmopolitical Obstetrics
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12.
Kitzinger S. The social context of birth: some comparisons between childbirth in Jamaica and
Britain. In Ethnography of Fertility and Birth (Edited by MacCormack C. P.), pp. 181—204. Academic
Press, London, 1982.
13.
Heggenhougen H. K. Fatherhood and childbirth: an anthropological perspective. J. Nurse –
Midwif. 25, 21—26, 1980.
14.
Cosminsky S. Childbirth and change: a Guatemala study. In Ethnography of Fertility and Birth
(Edited by MacCormack C. P.), pp. 205—230. Academic Press, London, 1982.
15.
Gihanga D. The traditional birth attendant of North Karamoja, Uganda. MSc. dissertation. London
School of Hygiene and Tropical Medicine, 1986.
16.
Cham K., MacCormack C., Touray A. and Baldeh S. Social organization and political
factionalism: primary health care in The Gambia. Hlth Policy P/ann. 2, 214—226, 1987.
17.
MacCormack C. P. Buddhism, socialism and primary health care in Burma. Manuscript submitted
for publication.
LORNA AMARASINGHAM RHODES
Department of Anthropology, University of Washington, Seattle, WA 98195, U.S.A.
In this article Jordan demonstrates the deep and intractable nature of certain kinds of cultural misunderstanding. No amount of training, explanation, or interpretation and no amount of good will can bridge
the gap she describes between cosmopolitan obstetrics and the hands-on world of Yucatan traditional
birth attendants. This is because the mode in which our training/learning is exported depends on years of
(often enforced) schooling to produce individuals capable of the kind of abstract, disembodied thinking
involved in typical ‘strategies for development’. Anyone who has taught college students knows that
waiting-it-out is not a posture exclusive to traditional midwives but is the natural reaction of most people to
the usual forms in which much so-called education is purveyed.
Jordan mentions that there are, in fact, “many instances in our own culture of learning through observation
and imitation”. This primacy of imitation is concealed by our tendency to separate talk from action. Thus,
physicians, nurses and midwives in the United States are not trained the way the traditional birth
attendants are taught cosmopolitan medicine. Instead, the presentation of ‘material’ in the form of
lectures, texts, diagrams and pictures is followed and augmented by long periods of apprenticeship (for
physicians, the clinical years of medical school followed by internship and residency training). During
these periods talk is ‘tied to and supportive of action’ as it is for the Mayan midwives. For example, in
Becoming a Doctor Melvin Konner describes the process of learning surgery:
“Go ahead,” Marty (the chief resident) said impatiently, and Mike (the intern)
started to cut down into the fat. “This your first gall bag?” “Yeah,” said Mike. “I’ve
done four appies, though.” “Well, these are harder. Just do what I tell you and
you’ll be all right.” [1]
This kind of learning is necessary for fields in which direct action involves uncertainty and judgments of
multiple variables. In medical practice, where the work deals with personal danger and suffering, the
apprenticeship is arduous and prestigious.
Jordan says that the traditional skills and learning methods of midwives are invisible to their urbanized
teachers. In a similar way, the gap between classroom and apprenticeship learning produces a
visible/invisible division in our own medical practice. Thus, it is not so much a matter of our exporting a
method that works for us, as of our exporting half of what works for us. The other half is formally
acknowledged, but poorly understood and difficult to describe in the vocabulary available to us. This
‘situated knowledge’ carries less prestige and less truth value than more formal, written forms of
knowledge.
The problem is not only that there is an apparently unbridgeable gap between what is taught and what is
learned, but, as Jordan implies, that privileging a certain kind of teaching conceals the fact that it does not
work for us either. This is why those who work in medical settings n this country may be culturally
sensitive, yet find that a proliferation of charts, definitions and explanations fails to address the sources of
miscommunication. Furthermore, if we do not attend to the invisible side of our own practice, we miss the
many ways in which learning is contextualized, formed into stories and passed on through example. In the
passage from Konner quoted above it becomes apparent that a tension between visible and invisible
learning develops in the operating room. “Once they had set up a routine of cutting, sponging and
cauterizing, Marty felt free to start talking to me. He grilled me on the anatomy involved in this procedure.”
In describing the presentation of cosmopolitan obstetrics Jordan makes a telling point about the culturespecific nature of visual representation. The drawings, slides and other visual props of the training course
Jordan: Cosmopolitical Obstetrics
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are meaningless to the Mayan midwives, partly because they do not share our representational tradition
and partly (perhaps more fundamentally) because for them knowledge is re-presented primarily in stories
and situations. Perhaps a counterpoint to this is that many people in the west believe themselves to suffer
from a lack of spontaneity in action and submit to various kinds of physical and psychological training to
decreases their self-consciousness and depende3nce on abstract representation. In fact, we are
developing a whole industry of ‘workshops’ and ‘training seminars’ that offer adults opportunities to tell
stories, make context-based decisions, or ‘play’ at their work.
In showing so clearly how we export this kind of disability Jordan gives concrete from to the thesis of
Fabian [2] and others that our forms of representation are tied to an ‘imperialist view of the world’. And it is
precisely, a ‘view’, based on complex connections between visual representation, objectification and
culturally specific notions of time and space. For this reason, I’m not sure that world view is the best term
for the differences described by Jordan. The Mayans have something rounder, more embodied and less
linear than we customarily think of as a ‘view’. Like the teachers of cosmopolitan obstetrics,
anthropologists tend to confuse talk with doing; the term ‘world view’ suggests an orientation quite
different from the one Jordan actually presents.
Finally Jordan raises an interesting question about her own role. She says that the nature of her role as
consultant was unclear and that participant observation in the context of the training sessions involved her
in considerable ambiguity. She suggests in these comments how difficult it is for those in positions of
power to integrate alternative perspectives on practice; despite extended discussions it appears that the
fruits of her unusual understanding were simply regarded as ‘nonfood’ by the development workers. Thus
she makes us wonder how – or whether – we can convey the shape and value of ‘hedge-school
knowledge’ to those with the power to obliterate it.
REFERENCES
1.
2.
Konner M. Becoming a Doctor: A Journey of Initiation in Medical School. Viking, New York, 1987.
Fabian J. Time and the Other: How Anthropology Makes Its Object. Columbia University Press,
New York, 1983.
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