In a previous article we shared the first part of the experience of Maryla Cross’ travels to Guatemala and learning with rural midwives. In this second part she explains how the NGO she worked with provided culturally sensitive training with the midwives.
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A lasso and a nest – homebirth in rural Guatemala Part 2
The Safe Motherhood Project…
Providing practical training to over 1200 comadronas over 20 years, the Safe Motherhood Project began after a chance encounter between a comadrona and a Canadian visitor, resulting in an invitation to a local activist circle. The NGO was born, operating under a Canadian umbrella charity, Rose Charities. The teamwork across Guatemala, going only where they are invited and knowledge of the training spreads by word of mouth. Sometimes courses are cancelled at the last minute and sexual health and menstruation education sessions are arranged instead at local schools. Other times the team finds comadronas who have already completed the course wanting to come back again and again and bring their colleagues.
All funding comes from online and local donations, plus a strong network of donor organisations built up over the years who are regularly updated via the Facebook page. The team consists of a Guatemalan co-ordinator, a Guatemalan midwife/nutritionist, a Guatemalan comadrona, a Canadian labour nurse, a German homebirth midwife working in Canada, a Canadian homebirth GP and myself, a London homebirth and continuity midwife.
The circle…
For this training, the call had been put out well in advance and over 40 comadronas were able to attend over two weeks. We gathered in a circle under a thatched roof. A local nurse and sonographer, Aura, translated everyone’s words between Spanish and Q’eqchi’. Ranging in ages from mid-20s to mid-70s, we shared our hopes and expectations for the course, the distances we had travelled to come together and discussed the logistics of the week. The local municipality had organised accommodation for those who had to hike and bike and bus to get to the course. The comadronas shared how they had arranged birth cover whilst they were away from their aldeas. Two male comadronas – a relatively new concept spurred by a lack of other options – joined us. We were also honoured to host a returning comadrona, whose vast knowledge was evident in her enthusiastic participation.
The training course…
Through the hard work of the team, the Safe Motherhood Project has acquired some excellent teaching aids through various donations and the WHO. I had not seen many of the practise mannequins before, but it made sense that for such a practical course whose participants may not be able to read, we had a wide range of visual and hands-on learning options. Our focus was on early recognition of signs of concern in pregnancy and labour and managing this whilst arranging referral or transfer ASAP, if possible. Our skills and drills covered everything from handwashing to sterilization techniques for rudimentary birth kits, to breech birth management, pre-eclampsia management, shoulder dystocia management [ legend has it that Ina May Gaskin, American midwife, herself was taught the ‘Gaskin Manouvre’ for managing shoulder dystocia by a Guatemalan comadrona ] estimating blood loss and managing PPH, to culturally sensitive nutritional advice (in a land where pineapples and papayas grow all year round!). Newborn Life Support, abdominal palpation to feel the ‘coconut’ head and advising on contraception and family planning were also key. Sessions were book-ended with digestible verbal theory, centring on hands-on demonstrations with lots of visual cues, manual practice and repetition to enhance learning and participation. Despite the blazing heat, the sessions were super fun and the group’s initial shyness melted into a wicked sense of humour on all sides; whether acting out a birth scene, asking all of the questions, sharing stories or when our guest 18-month-old comadrona would take centre stage alongside the instructors and provide vehement support.
With a strong emphasis on the importance of comadronas as public health leaders in their communities especially for women’s and girls’ health and reproductive education, we discussed in circle some of our relative experiences. Problems were shared and the circle morphed into a series of familiar staffroom complaints about the system different only to our UK complaints by the very, very different context. Comadronas were not accepted by health centre staff or hospitals. Cultural awareness was thin on the ground. Women were not allowed to birth upright. Hierarchy was overarching and ritual disrespect negated lines of communication. Health care was expensive – not because the centre charged for care but because the centre had no supplies and sent labouring mothers or their families out to buy everything from disposable nappies to syringes to clean clothes (often suspiciously from shops owned by people known to the health centre staff). Comadronas confided that if they themselves purchased these items for the women, they would never see the money again. They would often not get paid if they advised women to transfer in labour. Let alone the cost of gathering men to carry the labouring woman strapped to a chair down the mountain to the nearest road and the price of combustible (petrol) which is almost the same as in the UK!
Crucially, the Safe Motherhood Project runs the course for health centre staff too and encourages these discussions. Local health leaders and a local doctor attended this course, who already had a visibly convivial relationship with some of the comadronas and all sides were enthusiastic about building relationships and trust.
A doctor in the Democratic Republic of Congo (DRC) once advised me to never run a course or a conference without providing food, because no one will come; as we all know, the most important networking and discussions at any event happen over the food. This course was no different and as everyone sat in the shade of the papaya trees, we got to know each other over our maize tortillas. Though Safe Motherhood is a secular organisation, we had been kindly hosted by Karren and Rocky, local missionaries who had been serving in the area for years and who had previously hosted the Safe Motherhood Project team six years ago. Karren and local cook Ana provided delicious lunches and snacks for all of us and frightened us with their tales of finding boa constrictors in the foundations and yellow bearded serpents in the thatch roofs!
Antigua, an invitation to a birth and the shock of an Irish bar…
After careful monitoring of skills learned, practiced and honed, with knowledge exchanged in all directions, the last day of the course arrived. The colourful graduation ceremony was attended by everyone from the last two courses in their best huipils and cortes. The ceremony drew the attendance of local municipal leaders, and everyone collected mementos on their phones before being bussed or biked away on helmetless motorbikes. Our van was loaded to the rafters and beyond with the equipment, ourselves and our meticulous driver Conrado, before setting out of the dusty mission on our way to Antigua de Guatemala.
I have not yet become accustomed to working in a rural area of a country where colour, lush landscapes and wooden huts are the norm; then arriving in a capital city surrounded by brick and mortar, with a busy tourist season and, of all things, an Irish bar. It’s as though I have crossed into a parallel dimension.
As a world heritage site and natural wonder – which you can navigate by knowing which of the volcanoes is behind you, beside you or in front of you – the tourist economy of Antigua de Guatemala is a thriving one. But here too birth is not equal and lunch with a German midwife living here for the last 30 years shocked us with the local statistics and her reasons for opening and running a birth centre to promote natural birth – private hospitals had a Caesarean section rate over 90% and public hospitals around 50%. Her clients were a range of city folk from Antigua or nearby Guatemala City, who came because they desired culturally appropriate care, wanted to avoid caesarean-happy hospitals or who were referred to her because they couldn’t afford care elsewhere. She ran the clinic, attended births, hosted placements and fundraised all through her charity Manos Abiertas. She hadn’t had a holiday in years and asked how long I was staying.
The future of midwifery in Guatemala…
As described in Part One, Guatemala has a tumultuous history of maternal health provision, navigating a delicate balance of Indigenous culture and western influence to reduce its MMR. Our group of comadronas informed us that governmental trainings had not improved over the years and were still often culturally insensitive. The comadronas wanted more hands-on and practical courses, which are seemingly left for NGOs to provide.
Guatemala once had a professional midwifery school, running from 1895 until 1960 when the school was closed (Garcia, 2023). A recent attempt at a solution has emerged in the small-scale training of the partera professional (professional midwife). This comprises of a return to university-backed training, in Spanish over at least a year, but with specific cultural caveats (Summer, et al., 2019). Students must be comadronas who will take their skills back to their communities. The Safe Motherhood Project are deeply proud that 14 of the first students to pass the required midwifery entrance exams on to this course were comadronas trained by them, who had, of course, passed with flying colours! The government is attempting to bridge gaps in other ways, with all healthcare professionals required to spend some of their studies learning about Mayan culture and beliefs to increase co-operation and Guatemalan law now ensures that all health centres offer lassos and upright birth equipment. We now understand that only with solid investment in health infrastructure, in addition to interventions such as training birth attendants, can countries drastically improve their MMR (SotWM, 2021). This is a slow process and not supported yet by monitoring of birth experiences in Guatemala. In the meantime, whilst the world goes round, the comadronas will continue their vital, god-given work, for as long as they are needed.
Call to action:
NGOs like the Safe Motherhood Project always need help with funding for equipment, travel, paying hosts, delicious lunches, and making the courses logistically accessible to comadronas. If you have been inspired and would like to find out more or would just like to donate, please go to: https://safemotherhoodproject.org/tag/guatemala/
If you would like to learn more about Manos Abiertas, please go to: http://asociacionmanosabiertas.com/english-donations.html
To watch Give Light and to donate, please go to: http://www.givelight.info
To learn about and join the Critical Midwifery Studies Collective, go to: https://www.criticalmidwiferystudies.com
If you are curious about the Maya Midwifery Immersion Programme, go to: http://www.mayamidwifery.org
Maryla Cross
Community and continuity midwife, Hypnobirthing instructor, London
May 2023
About me…
I am a Polish homebirth and continuity midwife, hypnobirthing instructor and organiser of the London March with Midwives 2021. I live on a boat in London with my partner and my bunnies. I have previously worked as a humanitarian nurse and project manager and am about to embark on a Master’s degree at City University. If you would like to chat or have any questions, please come up to me at a conference, contact me via email, LinkedIn or via my hypnobirthing website: https://www.mothermountainmidwife.org
References
Fien-Helfman, S. (2018) “Traditional mayan maternal health practices in Guatemala.” Available at: https://doi.org/10.1596/30199.
Garcia, K., (2023) “An observational study of teaching methods with low-literacy comadronas in urban Guatemala,” Canadian journal of Midwifery research and Practice, 21(3), pp. 53-63
State of the World’s Midwifery 2021. (2021). https://www.unfpa.org/sites/default/files/pub-pdf/21-038-UNFPA-SoWMy2021-Report-ENv4302.pdf
Summer, A., Walker, D. and Guendelman, S. (2019) “A review of the forces influencing maternal health policies in Post‐War Guatemala,” World Medical & Health Policy, 11(1), pp. 59–82. Available at: https://doi.org/10.1002/wmh3.292.
Vansintejan, G. A. (1983). The traditional birth attendant in seven countries: Case studies in utilization and training Public Health Papers 75. Edited by A. Mangay-Maglacas and H. Pizurki. Geneva: WHO, 1981. 211 pages. Available from WHO Publications, USA, 49 Sheridan Ave., Albany, NY 12210. $7.50 plus $1.25 Postage. Bulletin of the American College of Nurse-Midwifery, 28(5), 37. https://doi.org/10.1016/0091-2182(83)90148-9 (Accessed at Wellcome Library, 2023)