More than midwifery

Exhausted, Doña Ángela comes home in Concepción Chiquirichapa in Guatemala’s Quetzaltenango Department, beating dust off her skirt. It has been a hard day: two deliveries, a checkup and a counselling session – in which she finally persuaded Pedro and Inés that six children are enough. That is no easy task in a place where masculinity is often measured by the number of children.

Doña Ángela is a comadrona – a traditional midwife – with 40 years of experience. She is one of many women who play a fundamental role in health care in Guatemala. Comadronas attend more than 60 % of births in the country as a whole and well over 80 % in indigenous communities. Maternal mortality in Guatemala is 153 per 100,000 live births and infant mortality 45 per 1,000.

Comadronas attend far more births than do qualified health workers; but they lack just about everything: financial support, adequate training, equipment and, most important of all, recognition. They have hardly been integrated into the official health system.

Because of their background and their lack of formal training, comadronas often feel discriminated against. Language barriers add to the problems of communication with government health workers. When taking patients who suffered from complications to a hospital, Doña Ángela has often been told: “Why do you women interfere and do things you know nothing about?” She complains, however: “State doctors and nurses almost never come to our villages, we are the only ones women can turn to for help.” Doña Ángela has lost count of the times she has trekked through the highlands to visit women in remote villages. Now, she teaches courses for other comadronas – in their native language Mam. She wants them to be better prepared for their work than she was initially. The courses are sponsored by the Guatemalan non-governmental organisation PIES de Occidente.

According to Mayan belief, traditional midwives are chosen by God (Ajaw) and learn of their calling in a dream or through divine inspiration. However, many who feel chosen know nothing about birth preparation. In the past, ignorance, poor equipment and even a lack of awareness about sexual and reproductive health often had fatal consequences.

Of the women who die in childbirth, 70 % deliver at home. Bleeding and sepsis are the most common causes of death, due to unclean medical equipment. So comadronas need to be adequately trained and they require proper instruments. All too often, they even lack basics such as sterile gloves and scissors. They do not get much support in terms of working material or funds, and the government does not really rate their work. The demands comadronas face are high, but the state-run health system does not help them to rise to the challenges.

Important educators

Adequately trained comadronas are much more than midwives. They also spread awareness of contraception, family planning, cancer screening, sexually-transmitted diseases including HIV/AIDS and domestic violence. They enjoy the confidence of women and families and they are familiar with local culture, life, customs and institutions. They also speak the indigenous language. Doña Ángela is a figure of authority in her community. When she speaks, even men listen.

She has brought more than 3,000 children into the world, she says, and no one has ever died. Girls are often named after her out of gratitude, or she is asked to be the newborn's godmother. The comadronas rarely receive payment; their patients are as poor as they are themselves. “Occasionally I’ll get a few eggs, a small bag of corn, or maybe even a chicken. Or the family will invite me to dinner.”

At the human level, the women feel they are in better hands than in state-run institutions. Thelma, one of Doña Ángela's young patients, says: “I don’t have much money and can’t afford a hospital delivery, so I came to Doña Ángela. Since I became pregnant, she has looked after me and explained to me what is happening to my body, what I should pay attention to and what I should eat. She speaks Mam, has lots of patience and I have a great deal more confidence in her than I have in doctors at the hospitals.”

Since 2004, Guatemala’s Ministry of Health has been implementing a new policy at the local level with the aim of bringing down maternal mortality and reduce delivery risk – partly by setting up local emergency committees. So far, however, these efforts have only reached certain regions. The comadronas have been pretty much ignored. There is hardly any funding available anyway. The entire government health budget accounts for less than one percent of GDP. PIES de Occidente, based in Quetzaltenango, however, recognised the importance of the comadronas and has been helping them upgrade their qualifications since 1994. Doña Ángela was one of their first partners.

Disadvantaged Maya-Mam

The “Mam Area” of Quetzaltenango Department in Guatemala’s western highlands – where Doña Ángela lives and where PIES runs most of its projects – is an extremely underdeveloped region. Almost everyone there belongs to the Maya-Mam ethnic group, and ­80% of the people live on subsistence farming. Few communities have electricity, water or basic health care.

For many, a visit to a health centre involves an unaffordable whole day’s travel. So health care is provided by comadronas, health promoters, traditional healers and Maya therapists. Population growth, at five percent, is significantly higher than for the rest of the country, and the birth rate is almost twice as high as that of the non-indigenous population. Maternal mortality is 50 % above the national average. Many women have children too early in life; their reproductive phase often begins at 15 years of age and extends right through to the menopause. During this time, they often give birth to many children in succession. Methods of birth control and family planning are often unknown or not used.

This setting puts at risk not only the women's health. It also has a negative impact on their chances in general in terms of education, development and quality of life. Even compared with elsewhere in Latin America, Maya women fare worse than anyone in terms of education. The illiteracy rate is 72 %; only 15 % of Maya girls attend primary school. Infant and child mortality rates are above the national average; many children die of illnesses that could be prevented by minimal health care.

To escape poverty, many men migrate to the United States or Mexico, leaving their families behind. Sex education in schools is inadequate; and there are hardly any appropriate facilities for gynaecological and pregnancy checkups. Domestic violence is also part of daily life for many families.

Useful training

That is the environment in which PIES de Occidente works. In one project launched with the cooperation of action medeor, a non-governmental German charity, and supported by Germany’s Development Ministry (BMZ), 175 comadronas and 50 health promoters were given advanced training to help improve sexual and reproductive health in six communities. One special focus was on recognising signs of risk during pregnancy and delivery – and guidance on what needs to be done should they occur.

The comadronas prepared “emergency plans” with their patients to ensure swift and smooth transport to the hospital in the event of complications during delivery. Women’s groups and schoolchildren were educated about sexual and reproductive health, as well as about contraception and domestic violence. And communities are still being sensitised by radio spots, brochures, posters and information campaigns at markets, festivals and public washing places.

Two health centres operated by PIES have extended their services. On top of immediate health care, they also do cancer screening and give advice on family planning. The comadronas used the opportunity to visit these facilities with patients, examining patients and enhancing their own practical skills. Interaction with the state-run health system was intensified to permit a better referral system for patients and ensure swifter treatment in emergencies.

Success is noticeable. The comadronas feel better prepared and are more confident when dealing with public-sector health staff – with better treatment for patients as a result. They have fewer inhibitions about seeking the advice of a doctor in the event of complications. An illustrated manual has proved particularly helpful. The pictures serve to remind illiterate women of what they have learned.

Much-needed change of mentality

The education campaigns and the counselling provided by the comadronas are also bearing fruit: “In the past, people were often annoyed when we gave advice about family planning,” Doña Ángela reports. “Men would simply walk away. Now, people are listening to us and understand what is at stake – even the men!” This may be the beginning of a much-needed change of mentality.

Today, youngsters know more about their own body and about contraception. Even their parents discuss these once-taboo subjects more openly. At the health centres operated by PIES, there has been a surge in demand for cervical and breast cancer screening, family planning counselling and treatment of sexually transmitted diseases.

Despite the successes, however, Doña Ángela insists that a great deal more still needs to be done: “It is high time our work was properly recognised.“ She says she and her colleagues need more training opportunities and adequate equipment. She is deeply frustrated by the lack of things such as gloves, scissors, bowls and clean towels. “The comadronas' work will never end and I think we will never stop learning,” she says.