THE DOM FOR THE CRAFT AND THE GIFT FROM GOD: ETHNOGRAPHIC EXPLORATIONS AMONG THE TRADITIONAL MIDWIVES OF SANTANA

O DOM PARA O OFÍCIO E A DÁDIVA DE DEUS: EXPLORAÇÕES ETNOGRÁFICAS ENTRE AS PARTEIRAS TRADICIONAIS DE SANTANA

Abstract

This article studies the traditional midwives living and working in Santana, the second largest city of Amapá state, Brazil. We present and discuss the midwives’ worldviews, highlighting how the obligations associated with non-compulsory debts in the cycles of giving, receiving and returning are not limited to the relationship between the patient’s family and the midwife. According to local conceptions, the most important relations of obligation associated with the dom for the craft are those established between humans and God. The counter-gift is accomplished through patient care, but as a form of obligation towards God. Assisting the women who seek out the help of the midwives is thus understood as the adequate means of settling the debt with the divine entity.

Key words:
Traditional midwives; gift; reciprocity

Resumo

Este artigo trata das parteiras tradicionais que vivem e atuam em Santana, segundo maior município amapaense. Apresentam-se e problematizam-se as concepções de mundo das parteiras, destacando que as obrigações relacionadas aos endividamentos não compulsórios no dar-receber-retribuir não se restringem à relação entre família da parturiente e a parteira. Na concepção local, as relações relevantes de obrigação concatenadas ao dom para o ofício se estabelecem entre humanos e Deus. Grosso modo, a contradádiva é efetivada no atendimento às gestantes, mas como uma espécie de obrigação diante de Deus. Logo, o atendimento às mulheres que procuram as parteiras é entendido como o meio adequado de saldar a dívida adquirida com o ser divino.

Palavras-chave:
Parteiras tradicionais; dádiva; reciprocidade

This article studies the traditional midwives living and working in Santana, the second largest city of Amapá state, Brazil. Santana has approximately 101,262 inhabitants. Midwives from the region are represented by an organization with more than 300 members, the Aunt Cecília Central Association of Santana, located in the central district of the city. The ethnographic fieldwork was carried out between March 2015 and February 2016. The first four months of fieldwork consisted of regular visits to the association (in average three days per week). After this initial phase, the frequency of the trips to the organization declined, replaced instead by frequent visits to the house of some traditional midwives and observation of the patient care that they provided.

According to estimates by the Citizenship Promotion Agency of Amapá at the start of the 2000s, the state had 1531 active traditional midwives. The institutional relationship between these women and the public authorities dates back to the 1990s, when Janete Capiberibe¹ created the Amapá State Program of Traditional Midwives.

Good anthropology highlights the importance of devoting special attention to the singular contexts in which the categories elaborated by natives emerge (Strathern 2006). This means that the transcription, plain and simple, of native discourse is not a real alternative to the use of categories outside the group’s universe of meaning (Strathern 2014). As Peirano (1991) asserts in her critique of the vanishing of the author as a theoretical subject, anthropology’s greatest potential resides in promoting the encounter between native concepts and the discipline’s theoretical knowledge. Taking the arguments of these anthropologists seriously, in this article we look to show that it is not possible to fully understand the midwives’ perspective of their craft - and the values that inform their worldview - without taking into account the long-standing discussion in the social sciences concerning reciprocity, gift and counter-gift. Nonetheless, advocating the need to contemplate the role of the gift when analysing the craft of the midwives of Santana is not enough. It is, rather, a starting point for the journey we propose. We should emphasize that the text that follows does not represent an attempt to accommodate native speech and categories to academic concepts, but, instead, to engage in a dialectical movement between each, where anthropological concepts shed light on the fieldwork material and vice-versa.

Keeping this in mind, our objective is to present and discuss the worldviews of Santana’s traditional midwives in relation to the process of healing the female body and treating health problems associated with gestation, childbirth and the postpartum period, highlighting the fact that the obligations related to non-compulsory debts in the giving-receiving-returning cycle are not limited to the relationship between the patient’s family and the midwife. Indeed, what we intend to demonstrate is that the most meaningful relation of obligation associated with the dom² for the craft is between humans and supernatural beings. In other words, the counter-gift effected through patient care is articulated as a form of obligation towards God. Thus, the assistance of women in need can be understood as the adequate (and perhaps the only) means of repaying the debt towards the divine entity.

The real midwives

The discussion about ‘humanized’ childbirth and related themes has occupied an increasing amount of space in the fields of the human sciences and healthcare.³ Taking this into account, we believe that presenting and discussing the work and worldviews of the traditional midwives comprises a particularly relevant line of analysis, capable of further deepening the discussion produced so far in the field. The midwives’ work entails a range of activities that largely surpasses that of assistance during labour (Fleischer 2007, 2008). They provide advice, perform massages and puxações (pullings), along with recommending and preparing home remedies for cramps, coughs, gases, and aches and pains in general. In terms of patient care, they usually accompany the entire gestational period, caring for the woman’s well-being and ensuring that no major problems occur over the course of the pregnancy. Given that these midwives work in an urban environment, assisting the actual deliveries has become less and less regular. But when they do, they use basic materials, such as scissors, basins, alcohol and towels. Currently, the traditional midwives of Santana receive the so-called ‘Midwives Kit’ - distributed by the state and municipal Secretaries of Health, in partnership with the Brazilian Ministry of Health - which contains surgical gloves and cap, scales and an umbilical cord clamp.

There are approximately 300 traditional midwives registered with the Aunt Cecília Central Association of Santana, the only organization existing in the region representing practitioners. Its headquarters is located in one of the sections of the Victória Régia Centre, a space maintained by the Amapá state government that houses various social programs. At the time of the fieldwork, the association normally held three weekly meetings on Monday, Wednesday and Friday mornings. On these occasions, physical exercise courses were offered. The meetings also served to provide training sessions, hold celebrations and run enhancement courses offered by the state government, the Rede Cegonha (Stork Network)⁴ and the SARAH Hospitals Network.

It was in this space and among its frequenters that the first phase of the fieldwork took place. Contact was first established with the president of the association. Subsequently, the different activities held there were accompanied, while simultaneously looking to build the relationships that would allow us to approach the midwives. A total of 21 interviews were conducted during this period.

Later, as the visits to the association became less frequent, trips to the houses of three midwives increased. Dona Silva, Dona Rena and Dona Noca are considered real midwives⁵ by their peers. According to local understandings, this signifies that they are women recognized to have performed a considerable number of successful deliveries and whose services are frequently demanded in the locations where they live. The choice of approaching and establishing a regular relationship with Dona Silva was prompted by a recommendation from the president and other associates of Aunt Cecília. Recognized as one of the most experienced among them, Dona Silva was 75 years old in 2015. At the time, she was living in the Baixada do Ambrósio region, a neighbourhood situated in a marshland area of Santana,⁶ where part of the municipality’s poor population lives. Her house, where she lived with her husband, brother, three children and four grand-children, was constructed from wood and consisted of two bedrooms, a living-room and one bathroom. With 55 years of experience in prenatal care and more than 150 deliveries, Dona Silva performed her sessions, which entailed deliveries and pullings, on her bed in the room shared with her husband.

The choice of Dona Rena was also influenced by the opinion of her peers. Thirty-four of her 56 years had been dedicated to prenatal care and she had performed approximately 60 successful deliveries, all of which earned her recognition as a real midwife. Dona Rena lived with her husband and son in a brick house with four bedrooms, a living-room, kitchen and bathroom, in addition to a backyard where she planted herbs used in the preparation of home remedies, which were later bottled. Proud of her path, she enjoyed saying that she had also taken a massage course, which, in her opinion, gave her an advantage over her colleagues. Two of the house’s four bedrooms were reserved for patient care. One had been adapted to perform massages and pullings. The other was turned into a delivery room.

Our relationship with Dona Noca began during the meetings at the association and suffered no interference from its president. Always open to speaking about her experiences, she also held a prominent position among her peers. Then 88 years old, she reported having performed more than 100 deliveries, the first of which had taken place over 70 years earlier. She lived with her husband in the Nova Brasília neighbourhood, in a brick house with three bedrooms, a living-room, kitchen and bathroom and a backyard where, like Dona Rena, she grew herbs used for producing home remedies. One of the rooms of the house was reserved for patient care.

Of these three women, only Dona Silva still performed deliveries. Dona Rena and Dona Noca both stated that they no longer take on these services, the former due to her husband’s health problems, the latter due to her own health, which, she said, had been fragile for quite some time. Nonetheless, they each insisted that were a woman in labour to need them, a local category largely used to refer to the idea of urgency or necessity, they would never refuse to assist. These three women are also sought out by those wishing for counselling, home remedies, postpartum care and pullings. We had many opportunities to observe how they are respected and recognized as knowledgeable and skilled among other midwives and those living in their neighbourhoods. In part, this prestige is due to the fact that they have never once lost a patient. They talked of this fact with great pride and made a point of highlighting this aspect of their history. According to the women, this was an indication that they had a dom and that they were fulfilling the mission assigned to them by God with success. On the other hand, while they devoted less attention to their failures in their narratives, all three mentioned situations in which the baby could not be saved. Nonetheless, episodes of this kind were incapable of shaking their belief in their own abilities. These situations were, according to them, the result of God’s will and not of malpractice.

Among the studies carried out with midwives in Brazil, Fleischer (2007) highlights the fact that pulling is the most frequent activity performed by the women. This is also the case of Dona Silva, Dona Rena and Dona Noca. In addition to the deliveries and the ability to guess the baby’s sex, pulling is one of the main activities responsible for building their reputation in the localities where they work. Mastering this technique is an important aspect of the midwives’ craft.

As Mauss (2003b) indicates, technique consists of a form of knowledge that is based on tradition and which does not necessarily imply the use of tools, since the body itself may be both object and instrument of the technique. Similarly, Ingold (2002) asserts that technique does not depend on the use of instruments and that the human body is frequently itself the tool. Pulling is a good example. It is a form of knowledge based on the women’s manual capacity to reduce pain, adequately position the baby in the women’s belly, and perform a diagnosis. In addition, pulling is important because it is through this activity that the midwives and the patient’s family create social bonds. Fleischer’s argument (2007:150) that this intervention enables patients and midwives to foster mutual trust is pertinent, therefore. This dimension of pulling allows us to identify it as an activity filled with meaning. It is a therapeutic technique interwoven with a particular worldview shared by the midwives and those who seek their help. This activity is thus the means by which a determined form of social relationship - one that frequently endures even after birth of the child - is constructed between the parties involved.

Different forms of performing pullings exist and it is common to find technical variations from one midwife to another. For example, while most of them focused attention solely on the women’s belly, Dona Rena massaged the whole body. In her words, this gave her an advantage: up to now, I have never met a midwife who does massages like me. When we know, we massage the whole body. This is how she proceeded, pulling from head to toe, so as to relax the patient and make her comfortable before manipulating her belly. Nonetheless, she advises that certain parts of a pregnant woman’s body should not be touched during the gestational period - the spine, the arms and the face - as this may risk a spontaneous miscarriage. A lesson from God, she says.

Still on the topic of what we might call the dispute for status and legitimacy, Dona Rena liked to emphasize that, despite her age, her services were still in high demand, even from firemen, police officers and doctors. She also claimed that her diagnoses of the baby’s sex were invariably correct and that she had a successful track record in patient care. Although she no longer delivered babies, she continued to perform pullings. Talking to the women who sought her assistance during this period, they confirmed that Dona Rena was accurate in predicting the sex of the baby and the date of birth. Similar to the midwives observed by Fleischer (2007) during her research in Melgaço, Pará state, Dona Rena made her diagnosis and recommendations during the pulling sessions. It was also during this time that she prepared the specific home remedy required for each patient, explaining which herbs would be used and their functions. She also prepared bottlings, which contained more elaborate combinations of herbs. Finally, she offered a cleansing bath, using a formula made from extracts of plants, roots and herbs for the women to wash their private parts after childbirth.

Dona Noca used a different technique. Her pullings were performed directly on the woman’s belly. As observed when accompanying her sessions, she would ask the woman to lie down on a mat with her head turned to the street, or else it would not work (meaning that problems could occur during the pregnancy). She said that she was unable to explain the reason for this: she simply repeated what she had learned from the older midwives. During the pullings, she gently punched the soles of the women’s feet so that the baby settles in the mother’s belly. Like Dona Rena, she also prepared and prescribed home medicines made from herbs and roots taken from her garden. During one of our conversations, she listed the purpose of the medications: lavender and rosemary tea for the baby, peppermint tea for after the birth, used to dry the umbilical stump and other formulas that included lavender, castor beans and so on. Dona Noca was also widely recognized and held considerable prestige in her neighbourhood. During one of the observed sessions, the patient said that the midwife had been highly recommended by her friends and that she was known for accurately predicting the child’s sex and date of birth.

Dona Silva, on the other hand, had her own methods. During the pullings, she held the woman’s waist, swinging and pulling it upwards while the patient remained lying down. According to her, this technique was designed to put the child in the right position, something similar to what Fleischer (2007:130) called “spatial socializing of the foetus.” Use of the technique allowed her to modify the shape of the woman’s belly. On one occasion, one of her patients reported having already been to other midwives, but only Dona Silva had been able to solve her problem. She did not prescribe home remedies in her sessions, because, in her view, women these days don’t want to take these traditional medications, they only believe in the doctor.

For many of the midwives working in Santana, prayers are one of the stages of the pulling or the childbirth assistance, even among those who declared themselves to be protestants. Dona Noca, who as well as being a midwife identified herself as a healer, used to perform the prayer at the end of the pulling, but only if the foetus was more than 5 months old. According to her, should the prayer be performed before this age, there is the risk that the child would not be well-formed, which could complicate birth and cause a spontaneous miscarriage, because the child is in a rush to come out. When this risk period is over, Dona Noca prays to various entities, including Our Lady of Birth, who, she says, becomes responsible for the patient, thereby becoming the actual midwife. She also prays to Saint Bartholomew, responsible for setting the child straight, and Saint Raymond, who stands by Our Lady to receive the child, and Saint Margaret, who aids with expelling the placenta. Dona Silva and Dona Rena, for their part, do not pray during the pullings, saving their prayers for the moment of labour, when they invoke Saint Margaret. They said that during the pullings, they only talked to God through their thoughts.

Whether they are used when the mother is at risk or during the routine of pullings, prayers are, from their perspective, an essential element that has an important role in the success of their interventions. The prayer constitutes the very activity of patient treatment and cure. In this regard, not only does the pulling technique correspond to what Mauss (2003b) called an “efficient traditional act,” the prayer also has an actual effect, since, without it, the practice would be incapable of producing a positive outcome. This means that, from their viewpoint, the prayer is as important as their ability in terms of ensuring the success of the intervention. It is, therefore, an efficient traditional act that entails the sacred and performs the role of engaging and soliciting the interference of supernatural powers in order to assist in patient care (Mauss 1981a).

This provides an insight into the understanding that these women have of their craft and touches on some of the central questions explored in this paper. As Mauss suggested, prayer partakes of the nature of both ritual and belief, thus connecting representation and action. Within this ethnographic context, the capacity or ability of the midwives is necessarily associated with a dom from God. This means that in many respects receiving a dom also represents the existence of a special bond between receiver and donor. Hence, while the prayer prepares the body for divine action and calls on God to intervene, it is only successful insofar as there is a special bond between the divine entity and those chosen to perform this craft.

Both the midwives and the patients, at different levels, play the role of intermediaries in this relationship with God. If, as Mauss (1981b) suggests, a mediator is frequently necessary for the connection with the sacred, then, in the ethnographical case analysed here, the midwives comprise the intermediaries who place God in contact with patients, allowing the divine entity to intervene in order to ensure the success of the pregnancy and delivery. At the same time, patients are also mediators, since they become the means by which the midwives seek to settle the debt created by the gift received from God. In the next item, we look to deepen this analysis of the relationship between God and the midwives.

The dom

A consensus exists among sociologists and anthropologists regarding the role of the family and neighbourhood in the primary socialization of children, since these are the environments in which they incorporate values and abilities. In some locations, these spaces - the house and its surroundings, occupied by family members and neighbours - are where socially relevant and prestigious knowledge and techniques are transmitted and/or learned (Mauss 2003b; Sautchuk 2015; Brussi 2015). This is the case of the traditional midwives of Santana. All of these women, without exception, told us that they had not gone through any kind of formal learning process - such as a training program - in order to become midwives. Neither did this learning process involve the transmission of knowledge by more experienced midwives within a tutor/apprentice model, what Chamoux (1981:149) called “transmission by a master.” What can be inferred from the discourse of the midwives is that theirs was a knowhow acquired through practicing (during a moment of need or self-interest), observing and listening. Sautchuk (2015) observed something similar during his research with fishermen in rural Amapá. Focusing on the young people who followed this career, he reveals that the learning process does not occur by means of an oriented action, but through observation and participation in what the natives called services (Sautchuk 2015: 112). He suggests, therefore, that the most suitable way to classify this process would be as an “abrupt immersion in the service” (our translation) (2015:116). In a similar fashion, Brussi, in her analysis of the learning process of lacemakers in Ceará, emphasizes that this process is “individual and the path travelled by each apprentice is unique” (our translation) (2015:76).

Dona Noca said that she performed her first delivery out of necessity, when she was 15 years old and lived in Mazagão, a small town in Amapá. The episode occurred while she was keeping a neighbour company, who went into labour during the night. With no one around to assist them, Dona Noca was faced with the task of performing the delivery. According to her, at that moment, she supplicated for God’s guidance and for the health of both the child and the mother. She recalled the details of her first ‘abrupt immersion’ in practical experience: I cut the umbilical cord, I squeezed out the small amount of blood. And then I rubbed on sweet almond oil, and pulled and straightened her up. I handed her over to her husband eight days later. The delivery was successful and her ability, despite her young age, was widely acknowledged, creating the opportunity for her to assist other pregnant women. Although she is the great-grandchild of a midwife, she insists - just as other Santana midwives frequently assert - that she was never taught. She claims to have learnt by herself, out of curiosity, and that she showed an interest from a young age and liked to follow the older women closely, listening to their conversations and observing their treatment sessions.

Dona Rena also had reference points among close relatives: her grandmothers and step-mother were all midwives. She said that although none of them had the time or patience to teach her, her interest had always driven her to stick close to them, observing attentively during the pullings and deliveries. Like Dona Noca, the idea of curiosity is a fundamental element in her narrative. Curious even as a child, she was always interested in understanding what happened inside peoples’ bodies. She recalls that even at the age of 10, she had already demonstrated some knowledge of the craft. Had it not been for the older women’s interdiction, she would have been able to perform deliveries. She was born with this intelligence, she said. Her self-proclaimed precocious ability stirred jealousy and antipathy among girls her own age and the older midwives. It was because of this hostility, she felt, that she only got the chance to perform her first delivery at the age of 22. After this success, though, she gained a foothold among her peers and was able to build her career and eventually become recognised as a real midwife.

Dona Silva tells a similar story. Granddaughter of a midwife, she said that she has known these things ever since she can remember and that, even as a child, she already understood what was going on just from a baby’s crying and the complaints of the pregnant woman. Like Noca and Rena, Dona Silva used the expression curiosity as a socially relevant factor when explaining her life journey. She also enjoyed pointing out that she had never received proper training from the older midwives; she had learnt by herself.

The resemblance in the structure of these women’s narratives concerning their initiation and learning process is no coincidence. In highlighting that they had shown curiosity about the craft of the midwives ever since childhood, already knew some techniques and had an understanding of symptoms, pullings and childbirth (or, as Dona Rena put it, they already possessed this intelligence), they were expressing a conception shared among all the midwives: their abilities cannot be understood to be simply part of a training process. Hence they reveal the existence of a dom and the idea that only those women endowed with this talent gift continue to dedicate their lives to assisting pregnant women and other people seeking treatment.

This dom can manifest itself through various signs. One of these is the baby’s cry inside the mother’s belly. Crying in the belly is a signal perceptible only to women who have the dom. It means that the child will also possess the ability to perform this craft. Dona Noca, for example, said that the women who had this dom and were close to her mother while she was pregnant with her were able to hear her crying many times. The dom may also manifest itself through dreams and visions. Curiosity is a sign too that the child bears the dom. It indicates a premature interest motivating the child to always stay close to the older women, observing how they treat the expectant mother, how they prepare home remedies and infusions, and the techniques that they use. Both Dona Rena and Dona Silva pointed out, however, that crying in the belly and curiosity are not in themselves sure indications. It is at a moment of pressing need - when these women find themselves in an exceptional situation where they are compelled to help a patient on their own - that the dom is confirmed or not. Finally, it is their capacity to obtain a successful outcome in their very first procedure, and subsequently in other deliveries throughout their life time, that confirms the presence of the dom.

The idea of the dom as a gift from God is widely disseminated in the Amazonian region. It forms one of the central aspects of a perception shared not only by the midwives but also by the communities in which they work, a fact that can similarly be observed in other studies, such as Fleischer (2007), Barroso (2001), Silva (2004), Pinto (2010) and Chamilco (2001). In her research in Amapá, Barroso writes that, among her informants, the “dom is a privilege acquired through either family heritage, circumstance or divine calling” (Barroso 2001:92, our translation). The author goes on to explain these three consecrated forms of initiation: a) ‘family heritage’ refers to the knowledge obtained through direct contact with their mothers, grandmothers and other female relatives; b) ‘circumstance’ pertains to situations of need, when they have to perform an emergency delivery; and c) ‘divine calling’ refers to the situation where they receive a mission from God and thus do not need to undergo any training process. In her study with the midwives of Melgaço, Fleischer (2007:160) describes having observed two forms of initiation. The first involved “not being taught,” the process through which the woman discovered by herself how to proceed in an emergency. The second form of initiation consisted of “having the path revealed,” which refers to situations in which these women received signs of possessing this ability, even before their first delivery. In this case, the “dom can be manifested through weeping, in dreams, or in the face of an unexpected delivery; the important thing is that it was transmitted through a divine or supernatural entity” (2007:160, our translation).

The ethnographic cases that we observed combine the initiation and learning possibilities described by Barroso and Fleischer. According to their informants, the dom is conceded by God, making it a divine gift that, as a general rule, reveals itself during critical events (Das 1995).⁷ The three women discussed in more detail in this article also share this understanding: their dom is a real work of God, a divine entity without whom they could never become real midwives.

In her narrative on her first delivery, Dona Noca said that God had placed her in that situation so that she could become aware of her dom and pursue it. These women also count on divine intervention during their treatment sessions. Dona Rena, for example, said that she always knew how to diagnose and touch the patient’s belly because God was guiding her during these moments. From a similar perspective, Dona Silva frequently said that all her deliveries and treatments were successful because she relied on God’s presence during the most critical moments. She also affirmed that the courage and knowledge that allowed her to handle adverse situations were a sign of the dom given to her by God.

Dom and debt

Albeit indirectly, most of the studies on traditional midwives in this region explore the models of social relations established between midwives - women described as having a dom - and patients and their families. Yet despite this fact, a good part of these studies - and this is especially true in the case of those focusing on midwives from Amapá - failed to systematically analyse in detail the presence of the principles of giving and reciprocity that govern these relations. However, without paying proper attention to this discussion - one central to Anthropology since Malinowski (1978) and Mauss (2003a) - it is impossible for us to fully understand the conception that midwives themselves have of their craft and of the social relations established between these women and those who seek their help.

Mauss was the first to provide an in-depth explanation of the phenomenon encompassed by the acts of giving, receiving and returning. His interest in the theme was famously explored in his work The Gift (2003a), first published in 1925. In this study, Mauss continued on from Durkheim’s work and established a new landmark in French sociology, renewing the theory of social cohesion and founding the conceptual discussion of alliance and the nature of the symbolic (Caillé 1998). At the same time, the author moved away from philosophy and created a comparative methodology that allowed him to analyse different ethnographies in order to understand the exchange system in primitive societies (Lanna 2000). Mauss was particularly interested in a pattern recurrent in different kinds of relations between social groups: apparently voluntary exchanges were governed, in reality, by an obligation, imposed on the recipient, through which the latter was compelled to reciprocate the thing given.⁸

The great question in Mauss’s essay is determining on which basis different groups establish and perpetuate social relations, whether or not these are steeped in antagonism. Mauss observes that not just the recipient is obligated to retribute, since the given thing itself will also return to the donor and to the soil from where it came. This is because, the author argues, the object exchanged has a spirit of its own that carries part of the original owner’s essence. Whether the object of the trade is rites, wives, food or anything else, the fact remains that what is being exchanged is the spiritual matter of the given thing, which is thus responsible for the acts of giving, receiving and returning (Mauss 2003a: 202).

Thereafter, as Dumont points out (1971), alliance - outlined by Mauss in a non-systematic manner - becomes a central question in French anthropology. It is on the notions of alliance and the gift that Lévi-Strauss founds The Elementary Structures of Kinship (1982). Lévi-Strauss credits Mauss with the effort to transcend empirical observation. He argues, however, that Mauss, by considering the hau the ultimate reason for exchange, failed to move beyond the native categories for “the spirit of the gift” and thus reach the universal concepts of the subconscious mental structures. According to Lévi-Strauss (1982), the obligations of giving, receiving and returning express just one relevant obligation: exchange. The original catalyst for exchange was, he proposes, the incest prohibition, which consequently prompted the formation of alliances. In this context, marriage provides a favourable occasion for establishing generalized cycles of exchanges, by means of which different social groups create social bonds and forge alliances wherein social life is itself the expression of the movement of perpetual exchanges.

Godelier observes that Lévi-Strauss’s interpretation thus shifts the ultimate reason for exchanges from the “spirit of the gift” to the “big-bang of the appearance of language and the symbolic origin of human society” (1996: 36, our translation). For Godelier, what motivates exchanges is the wish to produce and perpetuate the social relations associated with “solidarity and dependence” (1996:124). Hence the mechanism that reproduces exchanges is found not in subconscious mental structures, but in the social structures that allow the creation of bonds between individuals and groups.

One way or another, throughout the decades, reciprocity has been a central theme in the discussion surrounding the preservation of the stability of relations between groups, as we can see in the works of Sahlins (1975), Godbout (2002), Caillé (1998, 2002), Godelier (1996), Strathern (2006), Gregory (1980), Weiner (1976), besides the aforementioned Lévi-Strauss (2003). The quest for bonds is thus the principle that governs social relations based on the gift. On this point, Gregory (1980) argues that, in a gift economy, exchanges are responsible for organizing social relations and the desire to perpetuate them is associated with the pursuit of expanding these relations. The circulation of things is connected, therefore, to the desire to create a relationship between the parties involved in the exchange. Even in anthropological works like those of Strathern that highlight the reified nature of the inequalities underlying this system, the gift signifies the production of social relations.

In the academic literature on traditional midwives in Brazil, Fleischer provides an in-depth and thought-provoking analysis of the role of reciprocity as one of the organizing principles of the social dynamic associated with the relationship between these women and the local community in which they work, seeking to overcome the dichotomies that oppose financial contracts and gifts through what she classifies as the “new terms of reciprocity” (2007: 157, our translation). The discussion raised by Fleischer stems from her ethnographic experience with the traditional midwives of Melgaço, who entered into ‘contracts,’ establishing financial agreements for the type of service offered to the patients. Contrary to what had used to happen, more and more midwives started demanding monetary payment in exchange for their services. Nonetheless, this did not imply a decline or suppression of the model of social relations based on the desire to constitute, maintain and cherish social bonds. Taking this into account, Fleischer elaborates two critiques of those studies of midwives that oppose market and gift. The first concerns the understanding that since the midwives’ craft is practiced within the realm of the sacred, the incorporation of monetary retribution represents a stain on their work (2007: 155). The second relates to one of the consequences of the latter. She argues that by conceiving market and gift as incompatible, these studies tend to interpret the increasing presence of financial agreements as an unequivocal sign of the distortion of “authentic midwifing” (2007: 156) and as a risk to the continuity of the model of sociability which these researchers consider ideal. Taking an opposite stance, Fleischer contests the idea that the “terms of reciprocity changed in Melgaço, but reciprocity remains the founding epicentre of the relations between midwives and their patients, even if money and material survival are also crucial” (2007: 201, our translation). According to the author, therefore, financial agreements constitute an additional possibility for retribution, regardless of which families still worked to maintain social bonds with the midwives. On the contrary: due precisely to this monetary aspect, they strived even harder to honour these agreements.

In Santana, most of the midwives stated that they did not charge for the services they offered. Many of them said they made no charge for the pullings and deliveries because they already received the midwife allowance, an Amapá State initiative that provides a monthly payment of R$ 150⁹ to the midwives registered on its training programs. Nonetheless, the existence of the social benefit did not prevent them from receiving counter-gifts in the form of goods and services, which were a demonstration of gratitude from the family of the patients. And sometimes, when the patients insisted, they received between R$ 2 and R$ 5 for the pullings.

Among the three women discussed in this article, only Dona Rena charged for her sessions. She said that she did so because all the material used in the pullings and other procedures were acquired with her own money. Furthermore, she believed that the care that she provided was special compare to the other midwives because of her skill: everything that I use to make the remedies and the pullings… It is me who has to buy everything, so I can’t do it for free. And no one does half of what I do, so I have to charge. This is why, she says, she normally charges R$ 50 for each session. However, she emphasizes that she does not refuse to assist those who lack the means to pay, sometimes charging less or even nothing at all, depending on their financial situation. The argument made by Dona Rena that she does not necessarily make her services dependent on monetary payment is particularly interesting in light of the previous discussion. Considering that her dom is a gift from God, she cannot refuse to assist someone in need. This is, in fact, her compensation for the gift received.

As Fleischer (2007) observed in a different ethnographic context, the relationship between patients and midwives in Santana is also intertwined with the desire and effort to establish and maintain bonds, and with the giving-receiving-returning system, canonized in the anthropological debate on reciprocity and gift. Nonetheless, our ethnographic case has a peculiar feature compared to the situation described by Fleischer. Among the midwives of Santana we can observe the existence of two dimensions to the reciprocal obligations associated with their craft. The first is found between human beings and involves the creation of social bonds in the sense developed by the anthropologists cited earlier. The other - and, in this native context, more fundamental dimension - regards the reciprocal exchanges between the midwives and God. This means that the obligations related to reciprocity - the non-compulsory debts intertwined with giving, receiving and returning - are not limited to the midwives’ relationship with patients and their families. Rather, the most significant relations of obligation associated with possessing a dom for the craft are established between the divine entity and human beings.

To have the dom bestowed by God implies taking on certain obligations in return. Mauss (2003a: 206) argues that the gods and the spirits of the dead were the first entities with whom humans established an agreement. According to him, this modality of relationship itself contains an ambiguity, representing a potential source of power and danger for the human side of the equation. At the same time that human beings with a divine dom - a divine gift - become earthly representatives of the message of the gods, or persons with the capacity to intermediate between the transcendental entity and other humans (who may elevate them to a position of social prestige),¹⁰ they acquire a debt that can never be repaid, leaving them in a state of perpetual obligation.

We can observe a parallel between Mauss’s arguments and the worldviews of the midwives. They have prestige in the areas where they work, seen by others and themselves as representatives and/or instruments of God. The three main characters discussed in this article portrayed themselves similarly. They sometimes said that God and other divine entities, such as the Virgin Mary, not only granted them this dom, they also intervened during their sessions. The claim that they had never been taught, frequent among these women, likewise served to highlight their privileged relationship with God. Dona Silva, for example, said: God taught me. It was Jesus who taught me how to perform deliveries. The people who sought them also shared this idea. In their view, these women were blessed with the most noble of abilities, the capacity to bring life to this world. That is why they were special.

It is vital to remember, however, that the dom is not an attribute of those possessing it. God is its true owner. He has granted it to these women so they can assist people in need as a retribution for the gift received. Hence, the dom - and the social prestige that it entails - has a cost and requires compensation. The latter is materialized through the assistance given to women and to other people who ask them for help in the areas where they live and work.

What we wish to highlight is that, in cosmological terms, the most valued partner for the midwives is God, not the patients and their families. This implies that the exercising the dom is associated with a feeling of debt and obligation towards God. It is with the latter entity that they strive to perpetuate a bond. Although the return for this divine gift is materialized through the care that they provide to those who need them, from the point of view of our informants, this craft represents a retribution to God and expresses their gratitude and the desire to maintain this particularly special relationship. In other words, the counter-gift is effected through patient care, but as an obligation towards God. The patients thus become the intermediaries in the relationship between God and the midwives. This is why these women said that, ultimately, they were answerable to this entity, who determined when they should exercise their dom and who would judge them at the end of their lives. Dona Silva, for example, frequently said that she only answered to God. It was he who had granted her the dom and, in return, she worked to fulfil her mission.

The idea that only God can determine even when they can provide patient care also reveals the perception of debt associated with the dom. Dona Silva, for instance, said that she thought about stopping many times and even made some attempts to do so. The last time this happened was when she fell sick. Feeling unable to practice her daily activities, she had a conversation with God. But shortly after asking God for permission to stop performing the work, she said, he revealed to her that it was not the right time. So she carried on with her mission.

The expression mission is widely used by these women. It is through this concept that they make explicit the idea that they must exercise their dom and cannot refuse to assist those in need. Dona Noca explained that she needed to fulfil her mission, not refusing patient care, even after she had slowed down her activities as a midwife considerably, remembering that God had granted her this dom for her to practice throughout her life. Once again, it is Mauss who provides the clues to understanding the behaviour of these women in response to the received dom. Examining the exchanges between supernatural beings and humans, Mauss argued that, in this modality of relationship, the gods always offer great gifts in return for small retributions (2003a: 208). Since the exchange is unequal, the humans invariably remain in a state of perpetual debt. Mauss’s interpretation is very similar to what we observed among these women. In their view, only God can determine when they have repaid their debts and, for this reason, regardless of a number of complicating factors, they never refused help in emergency situations, even when they felt impaired. Receiving the dom thus established a kind of counter-sacrifice involving the need to be available, indeterminately, to assist people in need. After all, no one wants to assume the risk of breaking the relationship with God.

In this context, the reactions to cases of abortion are interesting. As one might expect, this an issue intertwined with numerous legal and moral constraints.¹¹ Despite the taboo surrounding the topic, it was a recurrent theme of discussion during the fieldwork. From the very beginning of our relationship, when questioned about her services, Dona Rena responded, in a clear reference to attempted abortions: people come to my house all the time, a lot of women who are bleeding come looking for me and don’t even want to tell me their name because they are afraid I’ll take them to the police station. Although this theme appeared frequently, Dona Rena made it clear that she refused to provide the means for women to terminate their pregnancy through the use of home medicines or other procedures. In her words, God gave me this gift so I could save lives, not so I could take them away. Her mission was to help keep her patients and their babies healthy. Nonetheless, precisely because it was her mission to save lives, were she to judge that saving the foetus was impossible after an attempted miscarriage, she would not leave the haemorrhagingwomen to fend for herself: she would administer a herbal tea to help expel the foetus and stop the bleeding. Not, though, without telling the patient off later: I really scolded them afterwards! I’d tell them how the child would have been beautiful. Dona Noca had a similar attitude. She said that she refused to help women wishing to terminate their pregnancy because this was a crime in the eyes of God. But when someone who had attempted an abortion came to her for assistance, she would give them a tea to stop the bleeding. Although she knew some formulas that expel the foetus, she did not administer them, requiring the woman to go to hospital instead. For her, this amounted to a form of punishment: she (the woman) should feel pain, so she doesn’t do a mean thing like this again, taking the life of an innocent child.

An ambiguity hovers over the issue of abortion. Since the midwives possess a dom granted by God - to which the counter-gift is the care offered to people who seek their help, the majority pregnant women - they assert that they are opposed to abortion and precluded from performing procedures of this nature. This would represent a misuse of the dom, which would provoke God’s disapproval. At the same time, though, these women feel uncomfortable declining to help those women experiencing complications from an abortion procedure. This is why, despite frowning on this practice and reproaching the women concerned, the traditional midwives consider that they have the duty to help them. Not to do so would also represent a risk to the preservation of their special relationship with the divine entity.

Final Considerations

Many researchers have observed the associations established by the traditional midwives of the Amazonian region between their skills in performing this craft and the dom granted by supernatural entities, in particular God (Chamilco 2001; Bessa 1999; Barroso 2001; Pinto 2010; Fleischer 2007). As we demonstrated, this is also the perception among the midwives of Santana. As we have seen, Fleischer explores the interpretative possibilities stemming from the idea of dom, highlighting its exercising through patient care and the relations of reciprocity established between midwives and patients, while criticizing studies like those of Chamilco (2001), Bessa (1999) and Barroso (2001) that oppose the gift model and those based on monetary agreements.

Specifically concerning the traditional midwives of Amapá state, two of the main studies carried out in the region, by Chamilco and Barroso, fail to analyse in more depth the principles of reciprocity and gifts in this universe or explore the analytical potential of the notions of dom and mission. As observed in other works like Bessa’s (1999), these researchers concentrated more on characterizing the work of the midwives as expressions of human solidarity, altruism and goodness.

With respect to the relations between humans - in this case, those between midwives and patients and their families - we observed a very similar pattern to that identified by Fleischer in Melgaço. Nonetheless, there is an important difference. In the ethnographic context analysed by us, from the perspective of the women, the relations of obligation, gift and counter-gift between them and God occupied a central place. This observation further accentuated the dissonance between this study and those of Barroso and Chamilco. Without undermining the importance of the work of these researchers, our study highlights what we consider to be the shortcomings of their interpretations. Barroso, for example, analysing the findings of her fieldwork, seems to have made the mistake of incorporating the native discourse without properly discussing it. For this reason, she assumes that the native perception of the dom received from God effectively cancelled out the feeling or understanding, shared by the traditional midwives, that they are obliged to exercise it. This misconception is an interpretative error. Anthropological and sociological bibliography have demonstrated at length that a vocation or dom are not opposed to the idea of obligation. The notion of mission itself, which the researcher mistakenly uses to deduce that the midwives feel no obligation to perform the craft, is nothing less than the expression of the debt acquired in face of the received dom. Taking into account the description portrayed here, we hope to have made it clear that, according to the local conception, the exercise of the dom is understood as the adequate means to repay the divine gift, a form of obligation assumed towards God throughout life, a recompense that guaranties the continuity of a privileged relationship with this entity and high social prestige in the region where they live and work.

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• 14
  Translated by the authors

• 15
  Revised by David Rodgers

• 1
  The relationship between public authorities and public healthcare professionals will not be explored in this article.

• 2
  Text in italics indicates a native category or native speech. Dom is the native category used to refer to an ability and knowledge, possessed by the midwife from birth, that constitutes a gift from God. The closest translation for dom would be gift. However, to avoid confusing this concept with the analytical category ‘gift’ and to remain faithful to its original meaning, we chose not translate it in this text. All other native categories and speeches have been translated to English.

• 3
  An increasing number of researchers have discussed childbirth-related themes, including Carneiro (2015), Deslandes (2006), Dias-Scopel (2015), Diniz (2005), Fleischer (2005), Nonato (2007), Pereira (2000), Pulhez (2013), Rattner (2009), Rodrigues (2008), Salem (2007), Tempesta (2017).

• 4
  A Ministry of Health program that aims to implement a network of care to guarantee the woman’s right to reproductive planning and humanized attention to gestation, childbirth and postpartum, as well as to safeguard the child’s right to a safe birth and to grow up in a healthy environment.

• 5
  All the women interviewed during the fieldwork, regardless of their time practicing the craft and the prestige they enjoyed among their peers and in their community, said they carried the dom. Nonetheless, there is a certain consensus that the real midwives are those who, in addition to the dom, dedicated their life to this craft, repaying, in this way, the gift granted by God.

• 6
  These are the swamp areas, which are neighbourhoods, mostly composed by stilt houses, built on the riverside of the Amazon River.

• 7
  The women’s narratives about the learning process and initiation into midwifery also dialogue with Tuner’s observations concerning rituals of affliction, where the knowledge acquired through misfortune or dreams is central to the self-modulation of individuals as experts (Turner 1968).

• 8
  Writing about the simultaneously obligatory and voluntary character of the gift, Bourdieu (1996) argues that this inherent paradox is hidden by the hiatus between the acts of giving and returning. On this point, Douglas (1976) also observes that the perception of the voluntary character of the gift is a deceit, since its cycle bonds people in permanent commitments.

• 9
  Brazilian reais.

• 10
  Along the same lines, Godelier (1996:42) argues that those who receive gifts from gods “elevate themselves above the other men and women and are almost like gods, or, at least, they approach themselves to them” (our translation).

• 11
  In Brazil, inducing abortion is a crime (Brazilian Penal Code, articles 124 to 128).

Publication Dates

• Publication in this collection
  2017

History

• Received
  19 Oct 2016
• Accepted
  19 Apr 2017