Doctors released Alejandra Guevarra Villegas, 19, from the operating room after delivering her baby girl by emergency C-section in San Luis Acatlán, a small town in the Costa Chica zone in the Mexican state of Guerrero.Credit...

Midwives and doctors struggle to help women give birth safely during the grim days of the pandemic.

Doctors released Alejandra Guevarra Villegas, 19, from the operating room after delivering her baby girl by emergency C-section in San Luis Acatlán, a small town in the Costa Chica zone in the Mexican state of Guerrero.

Rafaela López Juárez was determined that if she ever had another child, she would try to give birth at home with a trusted midwife, surrounded by family. Her first birth at a hospital had been a traumatic ordeal, and her perspective changed drastically afterward, when she trained to become a professional midwife. “What women want is a birth experience centered on respect and dignity,” she said. She believes that low-risk births should occur outside hospitals, in homes or in dedicated birth centers, where women can choose how they want to give birth. In late February, Ms. López and her family were anticipating the arrival of her second child at their home in Xalapa, Mexico, while following the ominous news of the encroaching coronavirus pandemic. She gave birth to Joshua, a healthy baby boy, on Feb. 28, the same day that Mexico confirmed its first case of Covid-19. Ms. López wondered how the pandemic would affect her profession.

Rafaela López and her partner, José Hernández, awaiting the birth of their baby, with Rafaela’s daughter, Johana, 11, nearby. Accompanied by midwife Pilar Victoria Rosique, Rafaela López Juárez tried to manage intensifying contractions when her labor started inside her home. Her partner José recorded the timing of the contractions. Rafaela López examined Jessica Garcia Pérez, 32, while Ms. Garcia’s son took a photo during a prenatal home visit in Xalapa, Veracruz.

About 96 percent of births in Mexico take place in hospitals that are often overcrowded and ill-equipped, where many women describe receiving poor or disrespectful treatment. The onset of the pandemic prompted concern that pregnant women might be exposed to the virus in hospitals, and women’s health advocates in Mexico and globally expressed hope that the crisis might become a catalyst for lasting changes to the system. A national movement has made determined but uneven progress toward integrating midwifery into Mexico’s public health system. Some authorities argue that well-trained midwives would be of great value, especially in rural areas but also in small nonsurgical clinics throughout the country. But so far, there has been insufficient political will to provide the regulation, infrastructure and budgets needed to employ enough midwives to make a significant difference. During the first few months of the pandemic, anecdotal evidence suggested that midwifery was gaining traction in the country. Midwives all over Mexico were inundated with requests for home births. The government encouraged state authorities to set up alternative health centers that could exclusively focus on births and be staffed by nurses and midwives. As Covid outbreaks spread, health authorities around the country started to see sharp declines in prenatal consultations and births in hospitals. At the Acapulco General Hospital in Mexico’s Guerrero state, Dr. Juan Carlos Luna, the maternal health director, noted a 50 percent decline in births. With skeletal staffs at times working double shifts, doctors and nurses pushed through under dire conditions. “Nearly everyone on my team has tested positive for the virus at some point,” Dr. Luna said.

Funeral workers remove the body of a patient who died from Covid-19 at the General Hospital in Acapulco, Guerrero, Mexico. Employees of a German company, Sanieren, based in Mexico City, sanitized the Covid triage area of the Acapulco General Hospital. Medical personnel assisted María de Jesús Maroquín Hernández, preparing her for discharge from the Covid-19 intensive care unit at the Acapulco General Hospital. María de Jesús Maroquín Hernández contracted Covid when she was 36 weeks pregnant, and was hospitalized for five days at Acapulco General Hospital, four hours from her home near Ometepec, Guerrero, Mexico. Later, she gave birth to a baby girl, who she and her husband named Milagro, Spanish for miracle.

Inside the Covid-19 intensive care unit at Acapulco General, doctors treated María de Jesús Maroquín Hernández. She had developed breathing problems at 36 weeks pregnant, prompting her family to drive her four hours to the hospital. Doctors isolated Ms. Maroquín while her family waited outside, watching funeral workers carry away the dead Covid patients and worrying that she would be next. She was discharged after five days and soon gave birth, via emergency cesarean section, in a hospital near her home. She and her husband decided to name their baby girl Milagro — miracle.

A central hub for dozens of mostly indigenous communities, San Luis Acatlán, a small town in the Costa Chica area of Mexico’s Guerrero state, became a “zone of high contagion” during the pandemic. Signs warned residents to wear masks. Soldiers guard the Ometepec General Hospital in Mexico’s Guerrero state. As the Covid pandemic intensified, the public sometimes stormed hospitals and threatened doctors. Ometepec General Hospital was nearly empty at times, as the public shunned hospitals in fear. State health authorities had ordered the reconfiguration of many public hospitals to create separate Covid and non-Covid sections.

In Mexico’s Indigenous communities, women have long relied on traditional midwives, who have become even more important today. In Guerrero, some women have given birth with midwives at dedicated Indigenous women’s centers called CAMIs (Casas de la Mujer Indígena o Afromexicana), where women can also seek help for domestic violence, which CAMI workers say has increased. But austerity measures related to the pandemic have deprived the centers of essential funding from the federal government. Other women have chosen to quarantine in their communities, seeking help from midwives like Isabel Vicario Natividad, 57, who keeps working though her own health conditions make her vulnerable to the virus.

Salustria Leonídez Constancia and her daughter in-law, Citlali Salvador de Jesús, examining Juliana Toribio Teodoro, 27, in Yoloxóchitl, a small Mixteco community located near San Luis Acatlán in Mexico’s Guerrero state. Midwife Alma Delia Felipe Hidalgo attending a birth at Casa de la Mujer Indígena Nellys Palomo Sánchez, in San Luis Acatlán, a small town in the Costa Chica zone of Guerrero state. In the remote community of Pueblo Hidalgo, in the Southern mountains of Guerrero state, Isabel Vicario Natividad, a midwife, approached the home of one of her clients, Guillermina Francisco Flores, 38, pregnant with her fifth child.

Ms. Vicario performing a prenatal check on Ms. Flores. Melquiades Villegas Feliciano, 23, supporting his wife, Luisa Ortega Cantu, while Ms. Vicario helped the couple prepare for the birth of Ms. Ortega’s third child. Luisa Ortega Cantu’s newborn was kept attached to the umbilical cord and placenta for several minutes after delivery, a practice of traditional midwives. Isabel Vicario with Ms. Ortega’s baby.

In the capital city of Chilpancingo, many women discovered the Alameda Midwifery Center, which opened in December 2017. During the initial phase of the pandemic, the center’s birth numbers doubled. In October, Anayeli Rojas Esteban, 27, traveled two hours to the center after her local hospital could not accommodate her. She was pleasantly surprised to find a place with midwives who actually allowed her to give birth accompanied by her husband, José Luis Morales. “We are especially grateful that they did not cut her, like they did during her first hospital birth,” Mr. Morales said, referring to an episiotomy, a surgical procedure that is routine in hospital settings but increasingly seen as unnecessary.

Hoping to avoid the coronavirus, many women in Mexico sought maternity care at places like the Alameda Midwifery Center in Chilpancingo in Guerrero. During the initial months of the pandemic, the center’s birth numbers doubled. Members of the Maternal Health Unit of the Guerrero health care sector teaching local midwives about Covid protection measures and breast cancer detection methods. Midwives who took part in the course by the Maternal Health Unit received a set of P.P.E. Anayeli Rojas Esteban, 27, tries giving birth in a standing position at the Alameda Midwifery Center.

While Mexico’s state health authorities struggled to contain the virus, the situation in the nation’s capital further illustrated the dangers and frustrations that women felt. In the spring, health authorities in Iztapalapa, the most densely populated neighborhood of Mexico City, scrambled as the area became a center of the country’s coronavirus outbreak. The city government converted several large public hospitals in Iztapalapa into treatment facilities for Covid-19 patients, which left thousands of pregnant women desperate to find alternatives. Many sought refuge in maternity clinics such as Cimigen, where the number of births doubled and the number of prenatal visits quadrupled, according to the clinic’s executive director, Marisol del Campo Martínez. Other expectant mothers joined the growing ranks of women seeking a home birth experience, for safety reasons and to avoid a potentially unnecessary cesarean section. In Mexico, roughly 50 percent of babies are delivered via C-section, and pregnant women face pressure from peers, family members and doctors to have the procedure.

In July, Nayeli Balderas, 30, who lived close to Iztapalapa, reached out to Guadalupe Hernández Ramírez, an experienced perinatal nurse and the president of the Association of Professional Midwives in Mexico. “When I started to research about humanized birth, breastfeeding, et cetera, a whole new world opened for me,” Ms. Balderas said. “But when we told our gynecologist about our plan, her whole face changed, and she tried to instill fear in us.” Undaunted, Ms. Balderas proceeded with her home birth plan. Her labor, when it came, was long and increasingly difficult. After 12 hours, Ms. Balderas and her husband conferred with Ms. Hernández and decided to activate their Plan B. At 3 a.m., they rushed to the private clinic of Dr. Fernando Jiménez, an obstetrician-gynecologist and a colleague of Ms. Hernández, where it was decided that a C-section was needed.

Janet Jarman Juan Luis de la Torre Islas joined dozens of other parents waiting to receive vaccinations for their children at Cimigen, a small maternity hospital in Iztapalapa, Mexico City’s most populous and most densely populated delegation, that had become the epicenter of the virus. Nayeli Balderas, 30, in labor, with her husband, Javier Basilio Lara, 31, in their Mexico City apartment, where they hoped she would give birth. Ms. Balderas had expected a hospital birth, but after the pandemic began, the couple decided to try for a home birth to avoid the coronavirus. After hours of labor, Ms. Balderas’s baby still had not rotated into the right position for birth. The nurse midwives advised different birthing positions, but the infant still would not budge. Twelve hours later, the midwives took her to a small, private clinic for a cesarean birth. Ms. Balderas with her son, born by cesarean section in a small private clinic at 4 a.m. Maira Itzel Reyes Ferrer, 26 and her husband, Hugo Alberto Albarran Jarquin, 33, attended a class offered by an obstetric nurse and a 92-year-old traditional midwife who together blend traditional practices and modern medicine. Ms. Reyes had her first child a week later. Elva Carolina Díaz Ruiz, the obstetric nurse, massaged Ms. Ferrer as her contractions begin to intensify. Pilar, her midwife, right, was in attendance.

In September, on the other side of Mexico City, Maira Itzel Reyes Ferrer, 26, had also been researching home births and found María Del Pilar Grajeda Mejía, a 92-year-old government-certified traditional midwife who works with her granddaughter, Elva Carolina Díaz Ruiz, 37, a licensed obstetric nurse. They guided Ms. Reyes through a successful home birth. “My family admitted that they were sometimes worried during the birth,” Ms. Reyes said. “But in the end, they loved the experience — so much so that my sister is now taking a midwifery course. She already paid and started!” As winter begins, Mexico is confronting a devastating second wave of the coronavirus. Hospitals in Mexico City are quickly running out of space. The much-discussed government midwifery birth centers have not yet come to fruition, and medical workers at prestigious hospitals like the National Institute of Perinatology, or INPer, are working around the clock. Early on in the pandemic, INPer personnel discovered that roughly one-quarter of all women admitted to the hospital were testing positive for the coronavirus. Administrators set up a separate Covid-19 ward, and Dr. Isabel Villegas Mota, the hospital’s head of epidemiology and infectious disease, succeeded in securing adequate personal protective equipment for the staff. Not all frontline workers in Mexico have been this lucky; the Covid-19 fatality rate for medical personnel in Mexico is among the highest in the world.

Grecia Denise Espinosa tested positive for the coronavirus at the National Institute for Perinatology in Mexico City, and was admitted to the Covid unit where she gave birth by cesarean. Minutes after the births, Ms. Espinosa’s twins were examined and tested for the virus. Because Ms. Espinosa and her babies were in good condition, doctors encouraged her to breastfeed, provided that she wore a mask and face shield.

When Grecia Denise Espinosa learned she was pregnant with twins, she made plans to give birth at a well-known private clinic. But she was shocked by the high cost and decided to consult doctors at INPer instead. To her surprise, when she entered the hospital in November, she tested positive for the virus and was sent to the Covid-19 unit, where doctors performed a C-section. Maternal health advocates have long said that Mexico’s obstetric model must change to center on women. If ever there were a moment for health authorities to fully embrace midwifery, now is the time, they say, arguing that the thousands of midwives throughout the country could help alleviate pressure on an overburdened and often distrusted health care system while providing quality care to women. “The model that we have in Mexico is an obsolete model,” said Dr. David Meléndez, the technical director of Safe Motherhood Committee Mexico, a nonprofit organization. “It’s a model in which we all lose. The women lose, the country loses, and the health system and medical personnel lose. We are stuck with a bad model at the worst moment, in the middle of a global pandemic.”

Image Sunset over the Casa de la Mujer Indígena Nellys Palomo Sánchez in San Luis Acatlán, Guerrero.