Timmy Global Health

Conversations with Midwives in Quetzaltenango

By: Anna Pollock

One of the main goals of the Health Capacity Building Grant in Quetzaltenango is to improve the quality of care that Guatemalan midwives working in our target communities are able to give to reduce maternal and neonatal mortality and morbidity.  We have been working with the midwives in each of the communities as well as the midwives associated with CODECOT, the Quetzaltenango midwife association, to design and give quality trainings on themes that the midwives themselves identify.  In early January we held focus groups with two different groups of midwives to learn more about the past training of our target population, the conditions in which they work, the materials with which they work, and ideas for how we can better help them moving forward.

The first meeting was at CODECOT with four of the midwives on the Council, including the president and the vice-president.  CODECOT works with the Ministry of Health to decide which trainings will be held monthly in each of the municipios of Quetzaltenango.  The midwives informed us that trainings have been conducted on themes such as women’s rights, mental health, self-esteem, and medicinal plants, but that very few medical, technical trainings had been given.  Some themes we identified in which we plan to help CODECOT design and conduct in the future include: miscarriages, labor, infant care, and high-risk birth including adolescent pregnancy.

The second meeting, conduced at Doña Ana’s house in Buena Vista, was an entirely different experience.  Twelve midwives came, some from as far away as the coast (2 or 3 hours); others from communities so rural that a car cannot enter, just to share their thoughts with us.  Each woman talked candidly about her individual experiences working as a midwife in her community.

I started this meeting by having all the women introduce themselves and tell us how many years they have been working as midwives and how they got started delivering babies.  The stories were incredible – mainly young, sometimes prepubescent, girls, attending their first birth out of pure necessity. The women spoke of being born into their roles as midwives, whether or not they were interested (most initially were not). The community believed it was their don, or predetermined role in life, and they were thus sought out by their respective communities to attend births even before they had experience.  For all but one of the women, this meant that they taught themselves how to deliver babies with no prior formal training.  Some mentioned that they were trained by apprenticing with an older midwife, usually a mother or grandmother, or through dreams.  In Guatemala, before you can become a midwife you must dream about it, indicating you are able to fulfill your don.  In many instances, the midwives said that what they learned in their dreams guided them when delivering their first babies.  Nearly all of the women agreed that they did not start attending formal trainings at the community Centro de Salud until they had been delivering babies for more than 10 or 20 years.

During the meeting we again talked about the monthly trainings that the midwives are currently receiving and what themes they would like to cover in the future.  The topics most frequently mentioned in regards to future trainings were the desire to learn to put in an IV and/or basic injections, and how to put in stitches so that when women have small tears after birth they do not need to go all the way to the hospital for only one or two stitches. 

After covering the questions I had prepared, the conversation strayed into other interesting experiences and obstacles to adequate care that these midwives have encountered over their collective 204 years of experience.  Many midwives agreed that it could often be difficult to convince a family of a woman’s need to go to the hospital when complications arose during birth.  One midwife, Paulina, talked of women coming to her in labor accompanied by drunk husbands.  These bolos have refused to send their wives to the hospital when it has been necessary, saying that it was the midwife’s job to deliver the baby, that they had come to her, and she was to deal with whatever complications arose.  Another midwife talked of one instance in which a woman was hemorrhaging and, at the midwife’s insistence of going to the hospital, the husband said, “no, this is just how my wife is,” and refused.  Throughout the meeting a recurring topic, and what seemed to bother the midwives most, is that although they tell their patients to make an emergency plan in case something goes wrong during birth, to save some money, find a car, etc. many families chose to ignore this advice.  At the hour of birth, these strong women were forced to make decisions, even against the family’s wishes, to save the life of the mother and the baby, as best they could, but often with little support from the husband.

When discussing how and when the midwives determine that a woman’s condition is risky enough to need to be referred to the hospital for labor, one example mentioned was when a woman has high blood pressure.  Interestingly, when asked if the midwives take blood pressures with a blood pressure cuff, they said no, that they don’t have these supplies.  Instead they rattled off the accompanying symptoms (head ache, shortness of breath) and use the presence of those as a proxy for when to send a woman to the hospital for delivery. 

These candid conversations with these groups of midwives were incredibly illuminating and shed light on the real issues midwives face working in rural Guatemala.  They will help us as we move forward in setting up a larger training (most likely on neonatal resuscitation and the first 30 minutes of life) next summer.