Quibdo, Colombia – Nohemí Manco was just 14 when she delivered her first baby. She had no choice but to step in.

Her sister had gone into labour, and no one else was around. Their home, in the remote Colombian municipality of Unguía, was surrounded by dense jungle canopy, waterfalls and wildlife.

But healthcare options were limited. So too was emergency transportation, not that Manco could afford it.

Still, Manco knew what to do. Since childhood, she had watched her mother comfort pregnant women through humid nights and sweltering days.

She learned where to cut the umbilical cord, which teas to prepare to ease the pain, and how to care for women after birth. By the time her sister's water broke, Manco felt ready to help.

“I loved it. I wasn’t even scared, although my sister was a little frightened,” Manco recalled.

Four decades later, she estimates she has delivered about 1,200 babies in the coastal department of Choco — perhaps more.

“When a baby starts coming, it feels like sunrise. Everything is dark, and then it’s dawn," Manco, 53, said. "When the child arrives, it’s like joy and relief at the same time.”

Manco is part of a long tradition of "parteras tradicionales" — traditional midwives — who play a central role in many remote communities across Colombia, particularly among Afro-descendant and Indigenous populations.

Often the first point of care for expectant mothers in these areas, midwives monitor pregnancies, attend births and provide postpartum care.

In some parts of Colombia, hospitals can be hours or even days away. The isolation leaves many pregnant women and their newborns at risk of facing complications with limited medical care. That, in turn, can be fatal.

"There is a higher concentration of deaths, proportionally, in rural territories," said Liany Katerine Ariza Ruiz, a public health researcher specialising in maternal health inequality at Pontificia Universidad Javeriana in Bogotá.

"Midwives are therefore the main and most constant resource for rural communities."

'So much discrimination'

Many midwives, however, say they have faced discrimination within Colombia's healthcare system. They report being mocked, dismissed and sometimes refused entry at medical establishments when they accompany their pregnant charges.

"For a while, we felt the tradition was being lost because there was so much discrimination," said one midwife, 36-year-old Yuvianis Florez.

But traditional parteras like Florez and Manco say they do not reject modern medicine. Rather, they want a closer collaboration with it, to ensure the safety of rural women.

Colombia's tradition of midwifery is largely concentrated along its Pacific flank. A survey published in May found at least 1,742 traditional midwives active in the region, some 11 percent of whom are men.

But the population is rapidly ageing. Almost half are more than 60 years old — and 40 percent are illiterate.

Manco, however, is among those who believe that local midwives can serve as advocates for education and reproductive health in Colombia's underserved communities.

Only weeks before delivering her sister's baby at age 14, she too had given birth. But her own pregnancy came as a surprise to her. Sex education was limited, and access to contraception was almost non-existent.

"I still thought maybe the stork had something to do with it, but my belly kept growing," Manco laughs. Both her mother and grandmother gave birth to 19 children each.

Manco is now part of the Association for the Interethnic Midwives Network of Choco (ASOREDIPARCHOCÓ), a collective that connects parteras with training and mutual support.

The network has also helped act as a bridge between midwives, health institutions and pregnant women.

A guide for medical care

Among its members is Visitacion Perea, 64, a traditional partera in Yuto, a small town about an hour from Quibdo, Choco’s capital.

Perea is also a trained nurse who works at a local health centre. She regularly wears a polo shirt stitched with the logo of the midwives' association.

When Perea grew up, talking about sex and even naming intimate body parts was taboo. Like Manco, she knew little about pregnancy.

"I thought women gave birth by vomiting babies out," she chuckles. "You imagine all sorts of things."

But she sees her role as a partera as helping to educate local women and guide them towards medical care.

Recently, Perea received a late-night call about a woman in a remote community who was bleeding heavily after losing her baby. No doctors were available, and travelling at night would have been difficult.

"I told the people with her what to do and which plants to use to try to stem the bleeding," she said.

The bleeding stopped, but Perea said she insisted the woman go to hospital the following day.

Travelling for healthcare can be a dangerous act in Colombia. Certain areas have no paved roads, mobile coverage or electricity. Many communities rely on waterways for transportation.

Then there are the armed actors who control swaths of rural territory in the country. Some are criminal networks. Others are left-wing rebels or right-wing paramilitaries engaged in ideological conflicts with the government and each other.

"If a woman becomes ill in a remote area, transporting her by river at night, sometimes in areas with armed actors restricting mobility, becomes extremely difficult," said Ariza Ruiz, the public health researcher.

Cultural divides

The result is often elevated levels of maternal mortality in remote areas.

As of 2023, the national rate stood at 44.5 deaths for every 100,000 live births, according to Colombia's Institute of Health. But in departments like Choco and Narino, rates remain significantly higher, with more than 76 deaths for every 100,000 births.

Choco is one of Colombia’s poorest regions. Even when offered free medical appointments, some women are unable to attend because they cannot afford transport.

Others fear that their preferences will be ignored. Lucila Caizamo, a member of the Indigenous Embera Dobida community, recently gave birth, and she too is a midwife.

As a coordinator for nearly 230 other parteras spread across several Indigenous communities, she often travels hours by boat — sometimes driving herself — to reach and support them.

But she understands the reticence members of her community face when accessing healthcare. Being unclothed is not customary among her people.

"Some women in Indigenous communities don't like to go to hospitals to have a baby because they have to strip off naked and expose their intimate parts," said Caizamo.

At hospitals, women are also often expected to give birth lying flat rather than in upright or squatting positions, as is traditional. Caizamo has heard of cases where doctors ignore their pregnant patients.

"They do not respect the decisions that she wants to make," Caizamo said.

Faced with barriers to medical access and community distrust, Colombia's government has increasingly turned to traditional midwives for help.

To support midwives, the United Nations Population Fund (UNFPA) and Colombia’s Agency for Territorial Renewal (ART) have offered community birthing spaces and equipment, such as thermometers and blood pressure monitors.

They also hold joint workshops where parteras can train alongside doctors and nurses.

In parts of Colombia, including Choco, midwives can also receive certification to complete birth notification forms, formally recording the births they witness.

Collaborative training

Alina Bravo, the health secretary for Choco, believes that trained midwives can act as “first responders” to address gaps in her department's healthcare infrastructure.

Of Choco's 31 municipalities, only Quibdo has specialist doctors. Even there, Bravo said, services remain limited.

But she believes training midwives can help improve pregnancy outcomes. The learning, she added, goes both ways.

"We have learned that some of the herbal treatments they use can have similar effects to medicines," Alina Bravo told Al Jazeera.

"We’ve also learned techniques from them to understand baby positioning and pelvic movement that are not always taught in medical training."

Manco is among the midwives to benefit from the department's training efforts.

"We’ve learned to recognise the early signs of pre-eclampsia, something I didn’t know about before. We look for symptoms like ringing in the ears, headaches, and swelling in the hands and feet," Manco explained.

"And now, if I have a mother with a problem, I immediately call the hospital and ask their advice — or inform them we need to come to the hospital."

For Perea, her fellow midwife, the government assistance has coincided with a shift in how parteras are perceived.

"Before, the midwife was hidden," Perea said. "Not like now, when we can freely provide our services, and all the territorial authorities value us."

Yet, there is still a long way to go. Experts warn that midwives cannot fully compensate for a lack of medical resources. The role is also often unpaid.

"We can’t say that simply having a trained midwife with some supplies is enough. It is not," said Martha Lucia Rubio, an assistant representative for UNFPA Colombia.

"Although midwives in some ways replace a service the healthcare system itself is not providing, they still require support and very close coordination with the health system."

'Something we do not want to lose'

Though traditional midwives are no substitute for healthcare access, advocates hope their contributions to maternal care in Colombia's poorest regions will be recognised.

"We are doctors, psychologists, nurses, mothers, grandmothers and midwives," Manco said, adding that she hopes that, one day, parteras will receive a salary for their work.

Midwives often have deep roots in their communities. Each area has its own maternal care rituals, using local plants like chiva and martinica for teas and ointments.

They also have internal hierarchies, to ensure knowledge is passed along to new generations.

A new midwife starts as a "semilla" or seed. They graduate up the ladder to become "experta", an expert.

Maria Ignacia Espinosa Sala, one such "experta", is from an Afro-Colombian community in Puerto Meluk, a remote area in Medio Baudo, Choco. She remembers learning through observation and practice.

"When I was about eight years old, I would creep underneath the house with friends and watch through the gaps in the wooden floorboards to see how my grandmother delivered babies," Espinosa Sala said.

"We would take ‘pachas’ — a type of plantain — and use them to imitate what she was doing. One of us would be giving birth to the pachas, the other looking after her."

A few years later, her aunt taught Espinosa Sala how to attend real births.

Today, she estimates she has delivered more than 1,500 babies, with other parteras turning to her for advice.

Manco too has attained the level of "experta". She hopes to continue carrying on with her work long into the future.

"For me, being a midwife is a blessing. We do it from the heart, with love — and it is something we do not want to lose."