Midwives for Midwives - Creating Parterships to Strengthen Women's Healthcare

Midwives for Midwives: Protecting the Sacred Circle

by
Lesley Raunig and Jennifer Houston, CNM

María Catalina lives in a small village called Áto, about an hour and a half walk from Antigua, a colonial city in the Guatemalan highlands. The region is surrounded by volcanoes, and is an agricultural center for the production of corn and coffee. Catalina looks much older than her 38 years, and is plagued by chronic health problems stemming from a life of poverty and hard physical labor. She is married, and is the mother of eight children. Her oldest child is 18. The youngest was born recently in Áto with the help of traditional midwife María Fermina. Immediately after the birth of her eighth child, Catalina was weak and unable to sit or walk without fainting. Fermina transported her to Clínica Ixmucané in Antigua, a women’s health and birth center staffed by North American midwives. At Ixmucané, Catalina was given a thorough exam, IV fluids and a nourishing meal. The family stayed the night in the birth center accompanied by their midwife. They left the clinic to return in one week for a postpartum mother/baby visit which included family planning counseling. The care Catalina received was provided at no cost to the family, making this collaboration between professional midwives and traditional midwives and their clients more accessible.

Midwives for Midwives and Women’s Health International (MFM), is a North American non-profit educational organization . We are midwives dedicated to strengthening midwifery and improve women’s health through the midwifery model of care.

As North American midwives firmly rooted in midwifery philosophy and practice, we view birth as sacred and value the usefulness of evidence-based biomedical techniques and traditional midwifery skills. Traditional midwifery is grounded in the holistic model which views childbirth as an essentially normal physiologic process with powerful

emotional, physical, cultural and spiritual dimensions. The underlying framework of the

midwifery model is the understanding and value of connection; the understanding of relatedness of the body and mind, mother and infant, midwife and women, women and

their social context. This model is rooted in the concept of personal knowledge and power

as it relates to women's capacity to birth and draws relationship and relevance between the

individual women's customs, beliefs, preferences and values about birth and her body and

those who care for her or facilitate her birthing process.

Our mission is to improve midwives’ knowledge and skills, while preserving effective traditional methods. We believe it is critical to assist traditional midwives to organize professionally thereby positively affecting public policy regarding their role in maternal and reproductive health care in Guatemala. Additionally, we offer a clinical site to midwives from around the world who have successfully completed a midwifery program and want to deepen and expand their skills and have an interest in working internationally. Through culturally relevant and medically sound training, intercultural professional exchange, and the provision of women’s health care through our model clinic, MFM seeks to enhance midwifery systems by establishing universal midwifery tenents and knowledge.

Guatemala is a small Central American nation, approximately the same size as the state of Tennessee. It shares borders with Mexico, Belize, Honduras and El Salvador. Guatemala is a country rich in diversity, from the geography and wildlife to the various cultures and people that inhabit it. It is also a country full of contradictions. Amidst stunningly beautiful scenery, strong indigenous cultures and traditions, social inequities continue to be entrenched in Guatemalan society. Guatemala is ranked 31^st of the 32 Latin American and Caribbean nations; lacking in terms of basic human services such as electricity, potable water, medical care, education, literacy and life expectancy. Approximately 70% of Guatemalans live in poverty.(United Nations Development Report, 2000).

Guatemala has the third highest maternal and infant mortality rates in the Western hemisphere, after Haiti and Bolivia. Maternal mortality is measured at 200 deaths per 100,000 live births, and infant mortality at 51 per 1,000 live births. The rates are higher in rural areas. To put this into perspective, a woman’s risk of dying in childbirth in the United States is approximately 1 in 3,700 whereas in Latin America the risk is 1 in 130. (WHO, 1997).

For the majority of women living in Guatemala, traditional community-based midwives, comadronas, are the primary providers of maternal and reproductive healthcare. Approximately 60-70% of all births in Guatemala are attended by comadronas, 90% of these in rural areas. It has been estimated that fewer than 62% of Guatemalan women use a modern contraceptive method, condom use is less than 3%, and 42% of the population has no regular access to healthcare. Despite the fact that the comadrona is the major provider of health care for women in Guatemala, and has great potential to impact maternal and infant mortality, she receives little recognition or support for her contribution. Although comadronas are respected members of their communities, with intimate knowledge of the cultural and societal contexts of pregnancy and birth, they are marginalized by the health care system and have not been included in any formal training system.

Unfortunately, the official response to the Guatemalan healthcare crisis has been a concerted effort to exclude midwives from the formal healthcare system through the promotion of institutionalized births. The focus has been on limiting the role of comadronas rather than providing them with culturally appropriate and relevant training; disenfranchising them rather than recognizing and utilizing them as the valuable human resources that they are. Midwifery training in Guatemala is inconsistent and inadequate. Midwives work with a population suffering from severe health problems, lack of infrastructure, and with extremely limited resources. The few midwifery training programs that do exist in Guatemala have been focused on identifying maternal risk factors, and transferring to hospitals. Preventative care, lifesaving skills and an opportunity to practice clinical skills are missing from training programs . When midwives transfer their clients they are not allowed to enter the hospital with their client and are often blamed for bad outcomes. Comadronas and families are frequently subjected to disrespect and abuse in addition to substandard, unsafe care when they do interface with the formal health system..

Cultural, logistic, and economic barriers make the safe and timely transfer of a mother in case of complications very difficult. As a result, the comadronas find themselves in the predicament of working under a mandate to transfer women with complications, but without necessary training to identify and adequately manage emergencies, or community resources and support to follow through with a transfer when it’s needed. With cesarean section rates and resulting complications (primarily infection) as high as 42%, a larger number of Guatemalan women are actually being put at greater risk, worsening rather than improving maternal child health outcomes (Siglo Veintiuno, …..).

The World Health Organization has stated that “ the person best equipped to provide community-based, technologically appropriate and cost effective care to women during their reproductive lives is the person with midwifery skills who lives in the community”. In spite of this recommendation, Guatemalan health policy is limiting the scope and breadth of midwifery practice, denying women their fundamental right to have a safe delivery in the setting and with the caregiver of their choice.

MFM’s training for midwives has grown out of years of working intimately with them, learning who they are, what their beliefs and customs are and what they want to learn. A curriculum was co-creatively designed that builds on existing knowledge and skills and preserves effective traditional methods. We use an adult learning model, and offer a clinical site for applying skills and practice. Our unique training method is gaining popularity and will be replicated early next year in collaboration with several Guatemalan NGOs, including ASECSA (Asociación de Servicios Comunitarios de Salud/Association of Community Health Services) and PAVA (Proyecto de Ayuda Vecinos del Altiplano/ Helping Neighbors of the High Plateau Project).

MFM provides full scope women’s health care and education through the Clínica Ixmucané, (“Ish-moo-canay”) named for the Mayan Goddess of creation. Our care incorporates effective “traditional methods” (information, touch, energy work, herbs, accupuncture, education, caring, creating safety and trust etc.) as well as evidence-based biomedicine. We provide competent, respectful care to clients, regardless of socioeconomic status or cultural background, in collaboration with members of the local medical community and Guatemalan comadronas. This setting fosters an intercultural exchange of ideas and methods and gives the traditional midwives a safe place to meet with each other and be supported by the staff at Ixmucané.

We have been deeply moved by the traditional midwives’ work. In spite of their lack of skills and equipment, the many high- risk women they care for, and the serious complications they deal with, they continue to serve their communities with devotion and diligence. Also impressive is their deep desire to learn more and to improve the care they give. Many of the midwives in training have had to overcome their own limitations of poverty, fatigue or illness, and the intense demands of their work. We’ve had midwives who have walked for hours to attend the training, and regularly attend our midwife support groups in spite of the effort it takes. We continue to be inspired by these strong and humble women.

MFM’s commitment to replicating quality midwifery care offers a unique site to midwives from the developed world as well. Clinic Ixmucané is one of the few midwife run free-standing birth centers that offers the opportunity to work in an international setting, with experienced midwives providing full scope care. Additionally, our apprenticeship and volunteer programs offer the opportunity to work with the traditional midwives who come for our regular meetings and transport their clients for collaborative care. The clinic serves women of all socioeconomic levels and cultural backgrounds. In a typical day, we see women of all ages from various countries with a variety of obstetric and gynecologic needs.

Clínica Ixmucané has been featured in several articles in the local Guatemalan press, focusing on the process of giving birth naturally (Prensa Libre, 2/01, “The Magic of Birth”) and the historical significance of midwives in the age-old struggle for women’s control of their bodies and reproductive processes (Siglo Veiniuno, 7/01, “Midwives: Appreciation for their Valient Contribution”). La Cuerda, a local feminist newspaper published an article in June 2000 that included acknowledgment of midwives’ role in women’s health, a project description, and a photo of the traditional midwives associated with the project.

A three month stay for apprentices and a minimum of one month for volunteers is suggested, and conversational and medical Spanish language skills are necessary. Ixmucané is an excellent place for beginning practitioners to integrate their existing skills and knowledge, and to gain experience working with a midwifery model in an international setting supervised by midwives. Volunteers have said that a month at Ixmucané revived their spirits and re-inspired their work.

Midwives everywhere share many common issues as they cope with the changes globalization has brought: worldwide health sector reform, growing use of technology, complex ethical issues, the widening gap in the distribution of world resources, and heightened awareness of gender issues in healthcare. Midwives must collaborate and think and act globally! This means the development of programs and policies that view reproductive health issues in the context of women’s social reality: programs for educational and vocational skills that aid women in making basic choices about their lives. “Women’s issues” such as comprehensive reproductive healthcare including sexuality education, health services and the reduction of systemic gender-based violence is critical for the health of women and the survival of the planet.

Midwives are the foundation of women’s healthcare and in addition to having a good knowledge base and skill level, midwives need to educate themselves about gender and human rights issues, encourage the education and participation of men in women’s health issues, and seek to affect public policy so that they themselves become decision makers.

At Ixmucané, we are committed to providing quality midwifery care, training and support of Guatemalan midwives, and opportunities for midwives to become change agents through our apprenticeship and volunteer programs. Midwives for Midwives, in a sacred circle of teaching and learning, giving and receiving, creating a more humane world for women everywhere.

Authors:

Jenna Houston C.N.M., M.S. has been working as a midwife and women’s health activist since 1971. She is the founder and director of Midwives for Midwives and has been in Guatemala since 1997 providing care and training at Clínica Ixmucané in Antigua.

Lesley Raunig R.N., L.M., a graduate of Seattle Midwifery School, has worked in Central and South America training community health workers and midwives.