“If there were a professional midwife in a health center as close to us as possible, it would be a great help. There have been so many problems lately … the need is great. I would ask that the Ministry of Health not abandon us…we’re in the communities. And if there were a professional midwife here, she would be interested in us, because we are working in her field together with her.” – Traditional Birth Attendant, Chahal, Alta Verapaz, Guatemala
My time in Guatemala has been packed-full of enlightening conversations such as the one above regarding the provision of maternal health services here. In Guatemala, it is estimated that over 70% of births take place at home under the supervision of traditional birth attendants, valued leaders of the community who learn from a rich tradition of birth practices passed down from generation to generation. This is particularly true among rural, indigenous, Mayan populations. While in most cases, deliveries go smoothly and without complications, when a problem does arise- such as hemorrhage or eclampsia- traditional birth attendants are not equipped to address them, and women and newborns can die or suffer morbidities unless referred to a physician. Yet it is estimated that there is only one physician per every 1,000 people in Guatemala.
I am specifically investigating perspectives from various stakeholders on a new concept for Guatemala, which can serve to address this need: professional midwifery. Midwifery utilizes both evidence-based biomedical practices and traditional skills to address the full spectrum of women’s needs during pregnancy, delivery and post-partum. Professional midwives are the primary birth attendants in many countries around the world, and it is believed that they are a crucial part of the solution to reducing maternal deaths globally. Yet, professional midwives are not part of the health workforce in Guatemala. But, the Ministry of Health in Guatemala is finally talking about adding this cadre of health personnel to the health system for the first time since 1960.
I am working with a local organization called the Centro de Investigación Epidemiológica en Salud Sexual y Reprodcutiva (CIESAR), or the Epidemiological Center for Sexual and Reproductive Research, which is based out of the public hospital San Juan de Dios in Guatemala City and led by Dr. Edgar Kestler. CIESAR’s sole aim is to reduce pregnancy-related morbidities and mortalities. CIESAR teamed up with Dr. Dilys Walker, a professor at the University of California at San Francisco, on their newest project which is funded by Saving Lives at Birth Grand Challenges. The project began in March with baseline data collection and will begin activities in October of this year. The project is called “Que Vivan las Madres” (“Long Live Mothers”) and will be rolled out throughout two entire departments in Guatemala- Alta Verapaz and Huehuetenango.
The project will implement a packet of interventions including:
1) PRONTO International’s low cost simulation-based training program to teach provider teams obstetric emergency management and teamwork.
2) A research-driven social marketing campaign encouraging women to give birth in clinics rather than at home.
3) Professional midwife liaisons charged with connecting TBAs to the formal health care system.
I am working on the third component: Integrating professional midwives into the existing model of care. My research consists of in-depth conversations with the stakeholders who have a vested interest in improving maternal health outcomes in Guatemala. I began by talking to national-level stakeholders: a congresswoman, the Vice-minister of Health, the founder of the only midwifery school in country- to hear their thoughts on midwifery in Guatemala. I then traveled to six different randomly selected health centers throughout the project area. Each remote site is several hours away from the others. At each health center I carried out in-depth interviews with health providers there as well as traditional birth attendants living and working near the clinic.
Despite the vastly different geographies and contexts, collectively, the message from all stakeholders has been the same: they welcome the idea of professional midwifery with open arms. Traditional birth attendants, doctors, government officials, and NGO’s alike talk about the shortage of health workers dedicated to maternal health services, the need for culturally appropriate birthing practices in facilities, the need for a stronger linkage between traditional birth attendants in communities and health facilities, and the importance of improving the quality of care in health facilities.
It is an exciting time in Guatemala. My research is showing that, fortunately, plans for the creation of professional midwives at the national level are consistent with the desires of those providing maternal health services on the ground. Guatemala is ripe for a change in its health workforce, and the time for this change is now. “Que Vivan las Madres,” is in a prime position to take the first steps towards translating policy into practice by implementing professional midwifery in this country for the first time in over fifty years. By summer’s end, my data will inform the project’s midwives’ scope of work, detailing specific, measurable activities for them to carry out in both clinics and communities. Their work in the 40 public clinics and their surrounding communities will help bridge a gap in health services and demonstrate to the Ministry of Health the benefits adding professional midwives to the health sector, by connecting the world of the traditional birth attendant, like the woman I quoted above, and the formal health sector, for the betterment of women throughout Guatemala.