The NAPA-OT Field School
Guatemala is a highly stratified country scarred by the civil war carried out against the Mayan population from the 1960s through the 1990s and violence is still tangible in Guatemala. Although about half of all births take place in hospitals (most in urban areas), Guatemala has a high rate of Caesarian sections and one of the highest rates of maternal and infant mortality in the Americas. Based on the knowledge that a majority of Guatemalan births are attended by lay midwives and the evidence from elsewhere that midwives can provide safer and healthier births, we decided to look at midwifery. We asked personnel at a health non-governmental organization what information they could use. They said that they would like to know what the barriers to closer collaboration between lay midwives (comadronas) and biomedical personnel are.
This became the research question for the midwifery team in the NAPA-OT Field School. We coded and analyzed interviews with 18 birth attendants and 15 recent mothers. We classified birth attendants into three groups: nine comadronas, one trained midwife, and eight doctors. Here, we compare reported birthing practices of comadronas and doctors.
We selected some of the practices from the recommendations of the International Confederation of Midwives (2013). Those that best illustrate differences and diversity in attention include birthing position, accompaniment, skin-to-skin contact, and umbilical cord.
Birth position. In the hospital, standard delivery is lithotomy (on the back, legs spread and feet in stirrups). Hospitals are not equipped to attend births in any other position, but three doctors (of eight) said that they try to accommodate a woman if she wants to deliver in a different position. According to one medical resident, “if the patient requests doing it in another position, it is allowed, although the majority used lithotomy.”
Five of the comadronas said that they allow women to deliver in whatever position she chooses, with lithotomy still being the most common. Two said that they typically deliver in squatting position with the husband supporting the woman from behind, hands under armpits while she uses his knees to support herself. Expressing this idea, a comadrona informed us that “they pick the position, sometimes lying down, on all fours, or standing.”
Accompaniment. Hospitals prohibit family or comadronas from accompanying women during labor and delivery, citing lack of privacy, space, and hygiene. Comadronas allow mothers to have at least one other person in the room with them, often the husband and mother-in-law. “The husband, the mother of the woman are generally the ones there. It is whoever the woman wants—and if nobody—[I] respect her decision,” another comadrona explained.
Skin-to-Skin Contact. Immediate skin-to-skin contact helps babies regulate temperature and breathing. All eight biomedical providers said that initiating skin-to-skin contact immediately after birth is routine practice. Most comadronas do too, but two comadronas said they wrap the baby in a blanket before placing her on the mother.
Umbilical cord. All providers agreed that the umbilical cord should be cut “when it stops pulsing,” although the time frame for this ranged from two minutes after birth to 20 minutes after delivery of the placenta.
Biomedical providers and comadronas use about half of the selected evidence-based practices recommended by the International Confederation of Midwives. However, in addition, other differences in access and knowledge contribute to misunderstandings between comadronas and biomedical personnel. “I feel that doctors don’t like us [comadronas]. For example, you arrive at the hospital…and [they say], ‘Leave your patient and go outside.’ They tell us [at our midwifery training classes] that we have a right to enter [the hospital] but when you’re actually there, the doctors act differently,” a comadrona elaborated. The perspective expressed by an obstetrics and gynecology resident at a public hospital illustrates these misunderstandings: “[Interacting with comadronas] is a little difficult because some comadronas are older and they don’t like that a person younger than them [tells them what to do]. They get a little defensive and sensitive. With some of them, you can’t give them any advice [about the patient].”
Differences in practice between biomedical practitioners and lay midwives are not dichotomous. Many comadronas combine Mayan cultural practices and explanations with biomedical treatments and explanations; likewise biomedical practitioners often incorporate popular beliefs into their practice. Three cultural practices emerged from the interviews: use of the temascal (sweatlodge), massage to position the fetus, and culturally appropriate handling of the placenta. Only comadronas used these practices. In addition, comadronas take cultural categories, such as the hot/cold humoral system, into account. While the open hospital gown and cold showers are standard practice in hospitals, many Mayan women perceive these “cold” practices as threatening the balance of “hot” birth.
Both doctors and comadronas recommended increased contact as a way to overcome these barriers. One resident noted, “I think it would be worth it to have an occasional meeting [between doctors and comadronas] or at least for these groups of people who are involved in patient care to get to know one another.” While a comadrona expressed similar desires: “We [comadronas] need to have more contact with doctors and nurses to understand and help one another. They need to listen to us and us to them. That’s how we’ll be able to better serve our patients.”
In the context of sharp health disparities and unacceptably high rates of mortality, comadronas play an important role in birth in Guatemala. If seen as community leaders who practice more than simple birthing, comadronas could have a positive impact on health outcomes if avenues for collaboration as equals with the formal health system are opened. This comparison highlights the complexity of birthing practices in Guatemala and illustrates how preliminary anthropological work can shed light on complex cultural practices.
Martha W. Rees, with Rebecca Irons, Devon Lara, Alina Mouritsen, Devon Myers and faculty co-investigators Stephanie Roche and Rachel Hall-Clifford. Rees, an anthropologist with 40 years of experience in Mexico in peasant economy, migration, and health, joined the NAPA Guatemala-OT field program faculty team for in 2017.
To submit contributions to NAPA Section News, please contact contributing editor Briana Nichols ([email protected]).
Cite as: Rees, Martha W. 2017. “Midwives, Comadronas, and Doctors in Guatemala.” Anthropology News website, December 13, 2017. doi: 10.1111/AN.719