Our goal is to improve maternal child health outcomes by helping to prepare and sustain local midwives in their communities and helping them to have a voice in local and national policies which affect them.
Since 1999, MMI Board members have served as an advisory and fundraising board to ACAM (Association of Midwives of the Mam Speaking Area). We have been working with this group of 40 Maya midwives from the beginning of their organization which was formed to address issues specific to indigenous midwives and the communities they served. These midwives had previously worked with several international groups who offered training courses designed to increase midwifery skills and address the high maternal and infant mortality rates in the area, However, despite these training sessions, as elsewhere in the world, there had been little demonstrable improvement in outcomes. Furthermore, the midwives had no voice in the programs being offered. They decided to seek their own solutions.
The model which developed was based on local control, long term commitment of N. American advisors, donors, and volunteers and constant re-evaluation of strategies.
There is a five thousand year history of midwifery in Guatemala. In the indigenous towns the midwife is one of the most revered figures and has great influence on health related decisions. She lives in the indigenous communities and speaks the Maya languages. Many traditional midwifery approaches are effective, readily available, and cost little. The basic care offered by the traditional midwife such as prenatal counseling, attending normal births, and postpartum care is very good. The high maternal and infant mortality rates occur most often in the most isolated areas and are often due to situations beyond the control of the midwife unless other factors are specifically addressed.
Midwifery training programs offered by international groups have had little or no impact on outcomes. This failure has resulted in blaming and further marginalization of indigenous midwives and a general movement of births into the hospital with all the attendant costs and risks of that setting and the biomedical model applied to birth. Furthermore, Guatemala currently lacks the hospital capacity to accommodate more than about 20% of the country's births. Affordable local providers and mid level facilities are badly needed.
The midwives recognize training sessions as one important component of their struggle to become skilled providers. However, they have identified significant obstacles to putting new knowledge into effective practice. They have sought our help in also addressing the following issues:
Though midwives do 80% of the births in the indigenous areas, there is no mechanism to pay them for their work. There is no place in the health care system for them to work regardless of their skills.
Payment for total prenatal and postpartum care, and the birth is dependent on their very impoverished client's ability to pay and ranges from nothing to a maximum total of $45. Many clients can only barter for services.
Young women are no longer choosing to be midwives for economic reasons, leaving some communities with no obstetrical provider they can afford, trust, or get to.
Physicians rarely choose to live and practice in the indigenous towns and rarely speak the Maya languages. The physicians that are available work in an office or local health clinic and are usually only available weekdays during business hours. A beginning physician's salary is about $12,000 per year.
The midwives families in our area subsist on about $3 per day. Children are needed to work in the fields. The cost of a uniform and books prevents most children, but particularly girls from going to high school and thereby attaining the foundation knowledge necessary to comprehend material covered in midwifery training programs.
The worst outcomes occur in the most isolated communities where the obstetrical provider often has the least training or resources and communication and transport are difficult.
A lack of written records and midwifery standards makes data collection difficult.
The midwives are also concerned about the impact of free medical care offered by many international groups. This undermines local providers. They ask how there can ever be an effective health care system in Guatemala if the majority of providers are expected to work for nothing and people expect to pay nothing for services?
Cultural & Environmental
- Midwives refer clients with risk factors or complications to the regional hospital. Many clients refuse to go, even in dire situations due to cost, lack of providers there who speak their language, preference for female providers, and care that is sometimes perceived as abusive. Midwives are not allowed to accompany their clients to the hospital or provide support and translation while there. Discharge plans are not communicated to the client's midwife for follow-up.
- The question of who is or is not a midwife is deeply woven into the Maya cosmovision. Highly skilled providers will find themselves without patients if they are not accepted by the local midwives and healers.
- Many plant remedies are effective, readily available, and cost little or nothing. Other traditional healing approaches, many involving the sweat lodge (Temescal or Chuj) are also effective. However, the use of these treatments is dismissed and demeaned. In addition, pharmaceuticals are generally not available to midwives and often prohibitive in cost.
- There is a lack of attention to environmental and social issues impacting outcome such as malnutrition, domestic violence, unsafe drinking water, heavy pesticide use, and poor air quality.
Material & Technical
- Midwives lack even the most basic equipment and supplies for their work. They have no access to life saving medicines due to availability and/or cost.
- Midwives lack means to call for advice or help in emergencies. Emergency transport is by volunteer firemen with poorly equipped vehicles.
- Midwives lack opportunities to learn and utilize computers, cellphones, and other useful technologies.
- Midwives lack a place to meet which will accommodate their group in order to share their experiences and improve their practice.
- Midwives lack anfacility such as a birth center to refer patients who need intermediate levels of care or who refuse to go to the hospital.
- Midwives lack a vehicle to transport clients to the hospital and one with four wheel drive to take care toisolated communities with very poor roads.
- The training sessions offered by volunteer groups and monthly lectures by a physician from the local health clinic have been given in Spanish and are mainly lectures.
- Spanish is not spoken at all by 40% of the midwives in our area and is a second language for the rest. Due to long standing lack of educational opportunities literacy levels are low and preferred learning methods are verbal plus demonstration followed by practice of skills. Written tests in Spanish do not effectively measure knowledge gained.
- Content of training sessions by outside groups is determined by them and often repetitive and/or impractical in the local situation. Content is frequently at a level which assumes a grasp of basic concepts not present. Some groups come with another agenda such as evangelism.
- Opportunities for supervised clinical experience for midwife apprentices has been undermined by some midwives reluctance to train another midwife who could compete for her meagre income.
- Outside trainers often come for single, short "missions" and therefore do not develop ongoing relationships with the midwives and community. There is a constant need for orienting new volunteers. Care given by volunteers is often episodic and can create unintended problems.
- Midwives have high status in their communities but low status with the local and national power structures. They have little input in planning for the health services of their communities.