Midwives Begin their Hospital Practice

Obstacles and New Beginnings in a Hospital Apprenticeship

The first week of September was the official start date for twenty-one of AMA’s women’s circle members participating in CODECOT’s (Association of Traditional Midwives of Quetzaltenango in English) midwifery program to begin their hospital practicum, an integral part of their two-year training. A significant component of CODECOT’s philosophy is that not only are midwives essential to the improved health and well-being of Guatemala’s rural indigenous population, but that they must also learn to marry their Maya medicinal knowledge with that of Western medicine through an involved apprenticeship.

This is why CODECOT requires them to bring their coursework to a hospital or birth center in order to learn how to assist doctors in labor, as well as to become accustomed to the professional medical environment. The students will work in multiple areas: outpatient care, labor and birth, postpartum care, immunizations (vaccines as well as home visits to high-risk pregnant women) and emergency care for a total of three months, one day a week from 8:00am to 1:00pm. They will work in the restricted areas alongside doctors and nurses, wearing medical uniforms. Weekly meetings in the CODECOT headquarters will take place for follow-up and answering questions, and at the end of the practicum, the students are required to present a final report to CODECOT as an evaluation of what they have learned.

Monday, September 5th was the start date for only 4 of the students, since the rest of them faced the challenging but common obstacle in Guatemala of discrimination. CODECOT coordinated the practice to take place in two hospitals, and unfortunately, the head of the department of labor and birth in the Regional Hospital of Xela rejected the plan for the CODECOT students to do their practicum in his department. He said that he did not want to be responsible for or supervise them and that midwives are in fact the reason why there are still maternal deaths in Guatemala. He claimed that recently 20 mothers have died in his hospital from malpractice by midwives, blaming them completely for the deaths without explaining the factors that were likely out of their control. AMA and CODECOT realize the necessity of training rural midwives in a hospital setting to synthesize Maya and Western medicine that saves the lives of Guatemala’s isolated population, however, some Guatemalan doctors are still resistant to accept the benefits of traditional midwifery. Luckily, after two weeks of searching CODECOT found another willing labor and birth department to host them in Momostenango, where a group of 17 of the students began their practicum on Monday, September 26th.

Unfortunately, this rejection is actually what the students were expecting and dreading: to encounter racism and discrimination in the public health system. A large majority of health personnel still do not understand the importance of the midwife, and prejudice against the indigenous is unfortunately all too common in Guatemalan society. Some of the students have reported to Mayra Izara, social promoter for AMA, that they were very nervous to begin their practicum yet are enthusiastic nonetheless about learning from professional hospital staff. Their fear of rejection in hospitals comes from being indigenous, their social and economic status, and for being illiterate, therefore causing them to suffer from triple discrimination. Even having to move forward carrying the weight of this fear, they remain positive and strong. Each one of the students has reported that they are walking into this practicum well-aware of their inherent worth as women, as counselors, leaders, and as a friend to everyone in their communities.

On the 26th they were received generously in the Comprehensive Maternal and Child Center of Momostenango by the center director Jorge Ariel Díaz, a doctor, an OB-GYN, and a nurse of the center. This type of center is called a CAIMI in Guatemala, or “Comprehensive Maternal and Child Care Center” in English. As part of the socio-economic agreement section in the signings of the Peace Accords in 1996, CAIMI’s were created as separate Maternity and Pediatric institutions from hospitals to provide specialized care to mothers and babies to reduce infant and maternal deaths by 50%, as well as help decongest Guatemala’s national hospitals. CAIMI’s were strategically positioned in the west of the country attend to indigenous communities, where they make the participation and coordination of midwives more accessible as well as take into account the knowledge of Maya medicine. CAIMI’s are legally required provide a space for midwives to be part of their programming and attention to mothers and babies.

The OB-GYN in charge at the “Momos” center expressed to them how he and the other staff are all in agreement with the synthesis of Maya and Western medicine, as well as the importance of both parties keeping an open mind in order to learn from each other having the shared goal of improving the health of mothers and newborns. He stated that science and medicine are always evolving, therefore one always has to be ready to keep learning. The midwives were given tea from the center’s own small medicinal plant garden, a small but important detail that shows they also respect and believe in the power of traditional Maya medicine. All of the students expressed their shared gratitude towards the center for accepting them and for the accompaniment AMA has provided them through this process, especially by the tireless and fearless leadership of Mayra Izara who translates Spanish to their indigenous language of Mam.

Midwifery is More than Just Babies

One very important characteristic of a midwife is their close companionship to their patients. Midwives provide a special degree of emotional support that one may not be able to receive from doctors, especially because normally midwives are from the same community or region as their patients and speak the same indigenous language. Since in Maya culture, midwives traditionally serve their communities for life and become highly respected elders, a midwife helping a woman in labor may have even been the one who delivered the mother herself. Some of them have delivered hundreds of babies, enough experience to surpass that of an Obstetrician. Midwives are carriers of precious and ancestral cultural knowledge, and through CODECOT’s programming, they are able to combine that knowledge with Western medicine to become general health practitioners and be certified to help deliver babies in a hospital setting.

Though there are many objectives in the practice of certified midwifery, two of the most important are to help prevent maternal deaths for rural indigenous women and also for midwives to act as advocates for women’s health. In Guatemala, the maternal mortality rate for indigenous women is double that for non-indigenous women, accounting for 71% of maternal deaths. Only 29% of indigenous women give birth in health facilities, as compared with 70% of non-indigenous women (http://www.ghspjournal.org/content/4/1/114.full#ref-list-1). When CODECOT students complete their two-year training and are legally certified midwives, they will not only assist in labor at the side of the patient depending on them but will also be able to triage potential issues so that pregnant mothers will know whether or not they need hospital care.

Being trained in a Western medical environment makes midwives more equipped to be advocates for female reproductive health. In rural and remote indigenous communities, there are largely no health services available due to geographic location and lack of public transportation at consistent times. Women have to travel long, costly distances to reach sufficient health care, which can be a deadly amount of time if there is an emergency. Many women when they are gravely ill actually resign themselves to the fact that they will die in their home because of fear of going to a hospital. They question: Who will translate in the hospital for me? Who is aware of and will present my medical history to the doctors? Who will provide me with emotional support as I go through a pregnancy or suffer from an illness? The midwife, or the “comadrona” (Spanish translation: “co-mother”) who will have been caring for them since the start of their pregnancy, is the medical health provider that they trust. CODECOT’s midwifery students are trained to be advocates for community members that unfortunately lack the education to know when hospital care is needed, and suffer from the fear that exists around being an indigenous person facing discrimination in a hospital. A midwife is a friend, mentor, and caretaker throughout the entire pregnancy and birth, as well as in illness.

Midwives don’t exist to make miracles: they are not witch doctors. They are an invaluable resource and a general practitioner for their community, and they deserve to learn from Western doctors and nurses in hospital environments to prevent the current and serious hospital overflow in Guatemala’s already struggling and depleted health care system. When someone is sick, a midwife can make a judgment call to see if that patient needs serious attention in a hospital and can then triage them to professional medical services. Or, they can evaluate if the use of traditional plant remedies to treat a minor ailment is sufficient. Healing illness with plant medicine is a concept that for many of us is difficult to comprehend because even with a recent surge in popularity, in our Western culture and mindset it is still not as widely practiced or taken seriously by our doctors. However, in Guatemala, the use of plant medicine is still alive and well and is an inexpensive and trusted medical resource. To help people access the services they need in a culturally appropriate and comfortable manner it is imperative to pay attention to and work with what is culturally relevant.

Sadly a lot of medical personnel in Guatemala are still not very open to the importance of the extraordinary midwife. There is still racism and discrimination that exists in Guatemala against the indigenous and their cultural values, as well as a deep misunderstanding of the role and benefits of something so traditional in the modern world. This negative attitude against the indigenous is an ideological and cultural issue in Guatemala that endures, and something that two small organizations run by women facing entrenched machismo values cannot easily change.

Nonetheless, we can continue helping midwives to be trained to integrate their necessary practices with those of the West. With the support of midwives, hospitals could be less clogged with patients, and sick or pregnant women would trust going to a hospital with their midwife: one who is comfortable with working in that type of environment and serves as their translator. By supporting midwives to become certified and professionally trained, we can continue to lower infant and maternal deaths in Guatemala. Inclusivity toward midwives and the incorporation of their assistance in labor and birth rooms develops an integrated and informed health system that better serves the health needs of Guatemala’s incredibly large indigenous population.

Laura Catania