Have you ever wanted to see what working as a midwifery in another country is like? Maryla Cross, homebirth and continuity midwife in London has been to Guatemala, a country with high maternal mortality, and shares her experiences of working with rural midwives. In this first part she explains why she went and the context of midwifery in Guatemala.
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A lasso and a nest – homebirth in rural Guatemala Part 1
A note on the joy of reaching out…
A few months ago, my team leader declared that I had too much annual leave left before the end of the tax year. Since I had not shown any inclination to plan my time well, she very kindly planned it for me; leaving me perplexed with what to do with this sudden allocation of free time.
Having no desire to hike a Welsh mountain or hang about at home (my usual suspects), I decided to reach out to midwives and organisations I admired, in the hopes that someone would accept a last-minute midwife to shadow them for a spell. The positive responses that came flooding back were overwhelming, and worth the effort purely as an experiment in the social reciprocity of midwives.
One of my sources of inspiration was an eye-opening documentary I had watched during lockdown, Give Light: Stories from Indigenous Midwives, directed and produced by Steph Smith. I had dreamed of meeting and learning from these incredible midwives, whom I considered my ancestral homebirth counterparts, working in extremely different conditions around the world. Steph recommended Maya Midwifery International to me, an organisation in Guatemala that runs an immersion programme with traditional midwives – comadronas (aka traditional birth attendants). Mindful of being an ethical voluntourist, I agreed a Spanish-speaking country would make sense, as I already speak fluent Spanish.
Whilst waiting for a response from Maya Midwifery, I researched other organisations working in Guatemala and came across the Safe Motherhood Project, a Guatemalan/Canadian Non-Governmental Organisation (NGO). They have spent the last twenty years working with local comadronas to improve maternal mortality rates in rural Guatemala and strengthen ties between traditional and professional women’s healthcare providers. I immediately felt a sense of kinship and destiny stirring in me, so I tracked down their contact details and pinged off an enthusiastic resumé-in-a-paragraph message. As luck would have it, they were heading out on an educational mission at exactly the time of my mandated leave! A few exchanged messages, a 4-hour intensive Zoom call that left me feeling like I had found my tribe, a serendipitous timing of events and some fundraising with kimchi later, I was on a plane towards Guatemala.
As a caucasian, European, homebirth midwife, in South London, with a British passport, a few languages and no dependents (other than two bunnies), I realise my privilege and freedom in being able to set off in the way I have. Still, there is always a gathering of courage before leaping in the hope that the net will appear. If ever the opportunity presents itself to you, I recommend you don’t hesitate (Cameron, 2020), if only for the wonderful responses you will receive when reaching out.
The stats…
Guatemala has a population of around 17 million people. Around 43% of the population identify as Indigenous, from Maya, Garifuna and Xinca groups. The Maya can be further divided into 24 groups, each with their own language (IWGIA, 2020). The Ladino (Spanish-speaking) population tends to congregate in the cities, whilst the Maya often live in inaccessible aldeas (communities) dotted around the rural and mountainous regions of Guatemala, famous for its coffee, cardamom, volcanoes, ancient temples and cloud forests.
95 per 100,000 women die of pregnancy related causes in Guatemala, compared to 7 per 100,000 in the UK in 2017 (World Bank Open Data, 2017), with Mayan women experiencing almost double that at 163 per 100,000. Maternal haemorrhage is the main cause of death. Women are recommended to attend at least four antenatal check-ups and around 70% of pregnant women in Guatemala can expect to have their birth attended by skilled birth personnel. Why then is the maternal mortality rate (MMR) so high? With a lot of questions and needing to check my assumptions, I re-read my study material from the Critical Midwifery Collective Summer School 2022, focusing on maintaining a decolonial mindset and an open curiosity.
A plane, a taxi, a bus, a 4×4 later and I arrived in a predominantly Q’eqchi speaking region, north of Cobán in the Alta Verapaz mountains. Nearest health centre able to provide emergency labour care? Chisec, 20 minutes away. Nearest hospital able to provide caesareans and blood transfusions? Cobán, 1.5 hours away. Heading south, the next hospital would be 4 hours away in Guatemala City. To the north, Flores was 3.5 hours away, almost in Mexico. These were just the driveable roads. I was out of my depth, with a comparatively comfortable 7-minute wait for a London Ambulance to whisk me to hospital, should I have any concerns at a homebirth.
The context…
Mayan culture and creation myths existed in Central America long before the conquistadores brought with them their own. More recently, a brutal civil war had raged for 36 years, ending only in 1996. Local population graphs in the health centre of Cobán showed me an hourglass curve with gaps where the middle-aged men should be, whilst stories of ethnic genocide, mass graves and land grabs exist in living memory. News of peace had reached the rural outposts slowly, and even now some people are still reluctant to trust any governmental services including health centres.
Government investment in healthcare and maternity care has seen an ongoing battle between international and national pressures (Summer et al., 2019). The World Health Organisation’s initial attempts to lower global MMR encouraged the training of Traditional Birth Attendants and their inclusion in health systems (Cabral, 1992). This ended in the late nineties after the endeavour seemingly failed to decrease MMR (WHO et al., 1992) and a new global drive for trained birth attendants and professional midwives developed (WHO, 2000). This had the effect of excluding Guatemala’s comadronas. Indigenous health advocacy organisations blamed the international policies for creating a deeper rift in the public health system, where a lack of cultural awareness led to pregnant Mayan women avoiding health centres because of how they and their comadronas would be treated (Tejada, 2012).
The book of Mayan creation, the Popol Vuh, reveres goddesses such as Ixchel or Ixmucane (depending on the region) for their many strengths and their powers of creation, sometimes directly naming them as midwives. Comadronas are similarly respected in their communities as healers, fate casters and powerful shamans with a divine calling, who earn their craft through dreams and apprenticeship (Paul, & Paul, 1975). Simultaneously, comadronas can be abused as women in a patriarchal society, often having to overcome their husbands resistance and shame to their work and can even be blamed by their communities for difficult births. Many are illiterate and are expected to provide their services vocationally for very little. Comadronas are spiritual as well as health caretakers, using ancient healing rituals such as chuj and temescal (bath and sauna), herbal remedies, the lazo and nido (lasso and nest), massage and ritual to tend to their communities (Tejada, 2012). Comadronas are required to certify with the government and attend trainings at their local health centres, though these are often run by reluctant nurses reading from a textbook and speaking solely in Spanish (Hernandez, 2017). Further training is largely left to international and national NGOs. Despite attending over 90% of rural births, comadronas are still not considered professional members of the maternal healthcare team and are excluded from global definitions of a midwife (SotWM 2021, UNFPA).
A woman in Guatemala can expect, on average, to live to 63 years old (UNFPA, 2023). Indigenous Maya women are formidable weavers; wearing homemade bright huipils (woven and embroidered blouse) and cortes (long woven skirt), with colours and embroidery styles denoting the region in which they reside. Part of a patrilocal society, they are expected to marry young, move into their husband’s home and fulfil their reproductive honour and duty by providing children as blessings to the family. Once pregnant, a Maya woman will turn to the local comadrona for guidance, choosing to birth upright at home with the comadrona’s lasso hanging from the rafters to support her, and a soft nest of her own cloths gathered on the floor around her. Multiple studies have explored the many reasons that Mayan women avoid health centres, ranging from fear, inaccessibility due to travel costs and distance, language barriers, disrespectful treatment, and a cultural dishonour to not be able to birth at home (Tejada, 2012). Comadronas are also disrespected at health centres by staff, shouted at, whether they bring women in early or late, told to wait outside even if they can act as translators and are then not present at birth to foretell the newborn’s future or perform other important rituals (Paul, & Paul., 1975).
In the next part of this story, I will explain the practical training provided by the Safe Motherhood Project and the experience of being with the rural midwives.
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
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
References
Cabral, Meena, Kamal, Imtiaz Taj, Kumar, Vijay, Mehra, Leila & World Health Organization. Programme of Maternal and Child Health and Family Planning Unit. (1992). Training of traditional birth attendants (TBAS / Meena Cabral … [et al.]. World Health Organization. https://apps.who.int/iris/handle/10665/61093
Cameron, J. (2020) The artist’s way: A spritual pathh to higher creativity. London: Souvenir Press.
Hernandez, S., Oliveira, J., & Shirazian, T. (2017). How a Training Program Is Transforming the Role of Traditional Birth Attendants from Cultural Practitioners to Unique Health-care Providers: A Community Case Study in Rural Guatemala. Frontiers in Public Health, 5. https://doi.org/10.3389/fpubh.2017.00111
Paul, L.O.I.S. and Paul, B.E.N.J.A.M.I.N.D. (1975) “The maya midwife as Sacred Specialist: A Guatemalan case,” American Ethnologist, 2(4), pp. 707–726. Available at: https://doi.org/10.1525/ae.1975.2.4.02a00080.
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.
World Health Organization, United Nations Population Fund & United Nations Children’s Fund (UNICEF). (1992). Traditional birth attendants: a joint WHO/UNFPA/UNICEF statement. World Health Organization. https://apps.who.int/iris/handle/10665/38994