A Sacred Calling: Midwifery in Guatemala
She walks on foot. She crosses mountains and lakes. She carries tradition on her back and healing in her hands. She was chosen for this.
Almost half of all births in Guatemala take place at home. There are hospitals, clinics, and centers in which people can give birth, but accessibility, both financial and geographical, is a constraint to their use. Over 40% of Guatemala’s population is indigenous. Around 75% of the total population lives in poverty, but 93% of indigenous peoples are impoverished. This, along with the fact that indigenous peoples live mostly in rural areas, disproportionately limits their access to basic healthcare.
Public healthcare is provided at no cost through hospitals and clinics, but their treatment is limited. There are private healthcare providers, but these are not an economic possibility for most people. This is why midwives, who attend 90% of births in rural areas, are crucial for their communities.
On a global scale, Guatemala’s infant and maternal mortality rates, though high, are not necessarily alarming. The infant mortality rate (IMR) as of 2017 is 21.3 deaths/1,000 births. However, compared to the rest of Central America, Guatemala has one of the highest IMRs.
The maternal mortality rate (MMR) of Guatemala as of 2015 is 88/100,00 births, although there are numbers as high as 153/100,000 births. This is most likely from a rural area, as these rates can be much higher, and even double, among indigenous populations. Just for reference, the United State’s IMR is 5.7 deaths/1,000 births and its MMR is 14 deaths/100,000 births, and those numbers are even considered to be high.
60–70% of all births are overseen by comadronas (traditional midwives), usually older women of rural communities, whose role is equal to what a doula or a lay midwife might perform in the United States. Their limited training does contribute to these poor birth outcomes, but they are still a crucial healthcare provider for many Guatemalans.
The comadronas have been practicing midwifery for thousands of years, guiding their communities through the process of childbirth by providing prenatal care, attending deliveries, and giving postpartum support to their patients. They also function more generally as medical and spiritual healers. As of 2018, there are 23,320 comadronas registered by the Guatemalan Ministry of Health, and probably more that are unregistered (for reasons I will discuss shortly).
In Mayan culture, midwifery is not a practice grounded in medical expertise as much as it is in spiritual legitimacy. Midwifery is a sacred calling, and midwives can be designated by other religious figures. Catalina, a comadrona in Nahualá, started practicing when a priest told her that her “‘destiny is to care for pregnant women.’”
Midwives can also be chosen through dreams and visions about childbirth. Chona, a midwife from San Pedro, reported having dreams about being a midwife, followed by visions that taught her “the signs of pregnancy, how to massage the pregnant woman, and to palpate the abdomen to feel if the fetus was in the correct position for delivery,” as well as proper procedures for cutting the umbilical cord and extracting the placenta. This calling is taken very seriously, as Chona and other comadronas interviewed explained that an ill fate will befall a midwife who rejects her destiny or tries to force it.
Comadronas who are not reputed to have ancestral wisdom are mistrusted and not accepted as birth attendants in their communities, which is why simply sending formally trained midwives into rural communities does not work. It was assumed that a midwife’s knowledge was inherently known, like it was for Chona, and as a result they do not have much formal training. Mayan midwives have certain practices that they have been using for hundreds of years. For example, they use special massages, called external version, to encourage a breech fetus to turn into the correct position for birth. However, their lack of formal training and access to resources does not equip them for delivering complicated births. As a result, the Guatemalan government, international organizations, and doctors have tried to address this issue in different ways and with varying degrees of success.
According to Maya Midwifery International, previous attempts to train midwives have had “little or no impact on outcomes,” and have actually encouraged “further marginalization of indigenous midwives.” This falls under what Robbie Davis Floyd would call a “birth model that doesn’t work.”
One example of this type of intervention started when the Guatemalan Ministry of Health began requiring all midwives to be licensed. Comadronas have to attend trainings where they learn how to “identify risk factors, good hygiene, and transfer complicated cases.” While this intervention was implemented with the intention of reducing bad birth outcomes, it presents its own issues.
For one, midwives first have to be able to get to the training. Chona had to make a three hour journey in a canoe across a lake in order to get to the nearest hospital for training. Not all comadronas are able to do this. Chona could not even interact with the doctors once there because they only spoke Spanish.
This highlights another problem with government training. Often these classes are taught in Spanish when, in fact, there are 23 different native languages spoken in Guatemala and almost half of Guatemalan women are illiterate. While these trainings do provide midwives with some resources, such as tools for cutting the umbilical cord, not all of them are free.
It seems that more and more organizations are recognizing this harmful strategy and are working on ways to achieve better birth outcomes that respect traditional midwifery practices and acknowledge the accessibility restraints of comadronas. One such initiative related to the prevention of a leading cause of maternal mortality worldwide, postpartum hemorrhage (PPH). A group of Case Western University students taught Guatemalan midwives techniques that they can easily and practically apply to their practices. The students explained that:
“New mothers should be encouraged to empty their bladders and immediately begin to breast-feed after birth. Breast-feeding releases a hormone called oxytocin, which is also administered in drug form as a first-line treatment for PPH.”
This group adapted western knowledge to midwifery practices in respectful ways that could be realistically applied in this context. This example also shows that fancy equipment and even medicine is not needed to teach life-saving skills.
There are many other groups and organizations that involve indigenous midwives and consult them on what is the best way to integrate more training into their practices. One such organization is the School of POWHER built by Saving Mothers. This school provides a 16-week training program for comadronas. They truly want this education to be indigenous-centered, so “Two head comadronas, graduates from the original class, have been identified as lead educators that will deliver the lecture portion of the school in Mayan dialect.”
Other organizations doing this respectful and effective work of centering and uplifting the needs of comadronas include Maya Midwifery International, Midwives for Midwives, The Colorado School of Public Health’s Center for Global Health birthing center in Trifinio, and Curamerica’s birthing centers in Huehuetenango.
There is currently an attempt to provide midwives with more skilled training through formal education. The Asociación de las Comadronas del Area Mam (ACAM), instituted by Every Mother Counts, has the first professional program taught at university-level for midwifery in Guatemala, as featured in the documentary Con Madre. Again, this education is indigenous-centered, as “The school recruits Indigenous students from regions with high maternal mortality rates and incorporates Indigenous traditions around pregnancy and birth, including plant-based medicine.” These midwives must also be accepted in their communities in order to practice, so they partner with traditional midwives, trading their educational knowledge for the spiritual wisdom of the older comadronas. As of now there is no official or legal recognition for these professionally trained midwives.
A priority among all attempts of training is to encourage midwives to transfer their patients to a hospital when difficulties arise. However, there are structural and cultural issues that prevent midwives from doing so. First and foremost is accessibility. Most hospitals are located in and around urban areas. Guatemala has a mountainous terrain, especially in more rural areas, making journeys to the nearest hospital arduous and time-consuming. Besides taking several hours, these trips can be expensive.
On top of this, there is also tension with hospital staff that discourages midwives from bringing their patients in for treatment. This dates back to the 1700s, when western interest in and attempted control over indigenous practices increased as doctors wrote “scathing condemnations” of Mayan midwifery. As is usually the case, these criticisms were fueled by racial power dynamics and ideological differences according to the western standard. The discrimination faced by hospital workers can be very discouraging for comadronas. Hospital staff have been known to berate comadronas for bringing their patients in too early or too late, despite the geographical barriers.
Midwives are not usually allowed to stay with their patients in the hospital, which is unsettling for both comadronas and their patients. Cac Perpuac, a comadrona in Totonicapán, a rural area, explains the dilemma of bringing her patients to the hospital:
“It really hurts when we tell our patients they have to come to the health centre, saying that they will receive good care — and when they do come, they are not treated well. They tell us we’re liars.”
It is undeniable that the lack of training for midwives to oversee complicated births contributes to the high rates of infant and maternal deaths, and there are definitely many circumstances under which they should transfer the care of their patients to people who are trained to help. But a hospital delivery does not ensure a positive birth experience. With the influx of Western medicine, some hospitals have become excessively medicalized, with c-section rates as high as 94%. One patient, Laura, described her experience in a Guatemalan hospital:
“It was very cold. After I gave birth I needed food and was very tired, but they only make and give food on their schedule… I did eventually get some food, but it was cold.”
The temperature and food was not the only chilly part of Laura’s experience, but the hospital’s treatment of Laura lacked the warmth and personal care that comes from a midwife.
Both comadronas and hospital staff think the other is inadequate. Hospitals are cold and uncaring, midwives are not skilled enough. But if this age-old tension is broken, positive change can happen. Barbara Rogoff offers an example of this dynamic through the experience of Chona:
The doctor in Sololá asked her how she knew what to do and who had taught her, and threatened her with jail if she was not qualified to practice. (The conversation was through a translator, to bridge between the doctor’s Spanish and Chona’s Tz’utujil.) The doctor presented Chona with a patient and asked her to determine when the woman would give birth. Chona examined the woman and diagnosed that the woman would give birth that same day about 12:30. The doctor expressed disbelief, but Chona’s prediction turned out to be correct, and the doctor asked her to deliver the baby.
This certainly does not always happen, but it does give insight into the intuitive training of comadronas and how this conflicts with western medicine, but also how it can complement it. As shown here, midwives can be an asset to a hospital. Not only do they often have more intimate knowledge of their patient, but they provide a cultural link between the hospital and patient. Doctors in turn can offer their medical training and access to life-saving resources, especially when dealing with complicated births.
Advancement can happen when doctors and midwives work collaboratively, and it seems that more of these types of relationships are being recognized for their value. One doctor interviewed in Con Madre acknowledged this tension, but admitted “we realize that culturally, midwives are very much accepted.” Sara, a Guatemalan nurse that works in the delivery ward, expressed her opinion in an interview that “midwives should accompany their patients to the hospital. A midwife’s presence would make the transition and treatment easier for the patient and the doctor.”
Recognizing the value of midwives as linguistic and cultural links between doctor and patient is key to solving conflicts surrounding childbirth in Guatemala. What must also be acknowledged is that doctors and comadronas do what the other cannot, and are saving lives as a result.
Sadly, there are structural problems that more comprehensive training alone will not solve. First there are issues of payment. There are no structures in the healthcare system that ensure a comadrona will get paid, especially because they do not work in conjunction with hospitals. Midwives mostly serve rural populations, which are also the most impoverished communities, and so families are not always able to provide payment even when engaging in a barter system.
There is no easy way to fix this. Clearly local appreciation and value of the comadronas is not enough for them to be properly valued monetarily, especially without widespread acknowledgement by the medical community. Furthermore, cultural beliefs have deep roots. Superstitions about conception and cultural mores about contraception cannot be easily changed to promote less births, and thus safer birthing conditions.
However, there is hope in this: over the past several years, both the IMR and MMR have been steadily decreasing.
While there is no evidence of a concrete causation behind this, I think that it lies in the training efforts by organizations that acknowledge the complexities of childbirth and value the contributions of indigenous midwives. These have been proven to be effective when implemented in local communities, as demonstrated by Midwives for Midwives’ Ixmucané Birth Center.
I also believe that more collaboration among midwives and between hospitals is crucial to link rural communities with the healthcare they need. Perhaps this could be developed through a nurse-midwife program. Though forms of these exist in some birthing centers, it does not seem that hospitals have implemented these programs.
When talking about midwifery, the craze is all about going natural. However, in this case, it seems that natural births are only safer when there is a contingency plan supported by trained medical professionals. Due to circumstances largely out of midwives’ control, births attended by comadronas can be dangerous. But without comadronas, the childbirth outcomes in Guatemala would be so much worse. They are serving the underserved. Their work is truly life-bringing and life-saving.
It is a sacred calling indeed.
