Indigenous Peoples make up 43% of the Guatemalan population yet they disproportionately represent 66% of all maternal deaths. While Guatemala reduced its maternal mortality ratio (MMR) by 50% between 2008 and 2015, disparities in MMR have persisted. The high maternal mortality rate among Indigenous groups is often attributed to the lack of institutional healthcare in rural areas, where most Indigenous Peoples live. Although 75% of births occur in hospitals and clinics in urban areas, only 33% of births occur in hospitals and clinics in rural areas. Discrimination and the lack of culturally appropriate and respectful care contribute to Guatemala’s high MMR among Indigenous women. Most services in hospitals and clinics are provided in Spanish by physicians and nurses even in rural areas despite it not being the primary language of most Indigenous women, which impacts the quality and experience of care. Being accompanied by a comadrona, or traditional Indigenous midwife, to a health facility is often frowned upon or prohibited. Hence, many Indigenous women feel more comfortable giving birth at home accompanied by a comadrona from their own community that they know and trust.
Comadronas are highly respected and trusted community leaders who perform traditional birth practices that are unique to Indigenous communities. These include abdominal massages, traditional steam baths (temazcal), praying, ritual burials of the placenta, and more. Historically, women would obtain the role of a comadrona through dreams and visions or they would come from families with generations of comadronas. Being chosen to be a comadrona was considered to be a gift and honor.
The Guatemalan government has recognized the importance of comadronas as a way to improve Indigenous maternal health outcomes and foster intercultural maternal healthcare. In the past, it has tried to support and integrate comadronas into the formal health system through training programs. Unfortunately, their inclusion efforts have been considered to be largely ineffective, inappropriate, and fragmented. Several government-run midwifery training programs have been conducted in Spanish and not in Indigenous languages, undermining the goal of culturally concordant care. Moreover, comadronas were solely viewed as “mechanisms for referrals” in these programs and most of the biomedical content taught in the trainings challenged the beliefs of traditional Indigenous medicine, making the integration of comadronas into the healthcare system difficult. Today, comadronas continue to be highly knowledgeable individuals that provide culturally appropriate care to thousands of Indigenous women and also help fill roles of family planning advisors, gynecologists, obstetricians, and pediatricians.
In addition to comadronas, the role of parteras, or university-level trained professional midwives, has reemerged in Guatemala. From 1895 to 1960, Guatemala had a professional midwifery school at the largest and oldest university in Guatemala, San Carlos University. To some extent, the school was closed because Guatemalan obstetricians viewed professional midwives as increasing competition. Like comadronas, parteras can play an essential role in filling in gaps in provider shortages and in delivering culturally appropriate care to Indigenous communities in Guatemala, but these training programs are limited and not widely accessible.
The work of various non-governmental organizations (NGOs) and civil society organizations (CSOs) in Guatemala center around providing culturally appropriate care. For instance, ALIANMISAR, which is an alliance of 400+ Indigenous women’s organizations, aims for all Indigenous women to receive respectful maternity care. This is reflected in their advocacy work around Indigenous women’s right to receive care in their own language and give birth in line with traditional Indigenous customs. From 2012-2018, ALIANMISAR’s advocacy work led to the creation of maternity units in various rural areas that allowed women to receive culturally concordant care. This included the creation of delivery rooms that enabled vertical delivery, temazcal installations, and bilingual staff. A major challenge that Indigenous women face in hospitals and clinics is having to communicate with staff that only speak Spanish. Therefore, having staff that are bilingual is important for women to feel understood and heard. The organization also dedicates itself to political dialogue, which allows them to sit down with authorities and evaluate whether the policies that are being developed are culturally competent and address the real needs of Indigenous communities.
In a complementary manner, Every Mother Counts (EMC) is raising awareness of the importance of providing culturally appropriate care for Indigenous mothers through stories and films. This includes their first film “No Woman, No Cry” and “Con Madre,” among many others. EMC has built relationships with two Guatemalan organizations, Asociación Corazón del Agua and Asociación de las Comadronas del Area Mam (ACAM), and has provided them with robust multifaceted support to improve access to quality and culturally concordant maternity care for Indigenous mothers.
Both of EMC’s partners focus on integrating comadronas and parteras into the Guatemalan healthcare system through training. Asociación Corazón del Agua trains professional midwives in the first university-level degree program in Guatemala. The program is a 3-year direct-entry midwifery program that is unique because it incorporates Mayan traditions around pregnancy and birth. They recruit Indigenous Mayan students from highly underserved areas of Guatemala and train them as professional midwives to provide skilled, compassionate, and culturally appropriate maternal care to Indigenous mothers. Another organization that is helping train and integrate comadronas is ACAM. Initially founded to address the need for high-quality professional education and training of Indigenous midwives, ACAM aims to better recognize and integrate comadronas into the healthcare system. They do so by providing high-quality training that closely resembles university-level training for comadronas.
Overall, comadronas and parteras are crucial members of the Guatemalan health system that provide maternity care to Indigenous mothers who often lack access to safe and quality care. The tremendous and often unrecognized work of these organizations empower comadronas and parteras to continue to provide culturally appropriate and respectful care in a skilled manner. The journey to integrate comadronas and parteras into the formal health system remains challenging. Yet recognizing their value and continuously supporting them is an important step towards improving the Indigenous maternal health situation in Guatemala.
Note: We would like to thank Melissa Gradilla, EMC’s Associate Director of Grantmaking & Impact, and Marisela García from ALIANMISAR (National Alliance of Indigenous Women’s Organizations for Health, Education, and Nutrition) for taking the time to meet with MHTF and share about their work. You can support them and learn more about their work on their websites:
ACAM’s U.S. sister organization: http://www.mayamidwifery.org/