Lay Midwives: On the Front Lines of the Fight Against Maternal Mortality in Rural Guatemala
Dona Clarita, an indigenous Kaqchikel Maya woman who has practiced as a lay midwife for 25 years, recently took care of ahome birth patientwhohad failure to progress in labor and needed to be referred to the hospital. On referral of her patient, she tearfully recounted to us, "The doctors at the hospital told my patient I was trying to kill her. You know I would never do that. Her labor was not progressingwell, so I referred her to the hospital. [The hospital staff] blame me for her complication. She wanted a home delivery, I was the one who insisted that she go to the hospital. This is not fair. " In our work as physicians and researcherswithMayaHealth Alliance, anongovernmental health care organizationworking to improve rural services for Maya communities, we hear stories like that of Dona Clarita on a weekly basis. Lay midwives, who are often the only care providers in the rural communities where they live, are routinely stigmatized for and criticized by the biomedical system for not promptly detecting and referring patients to higher level care. However, as the case of Dona Clarita highlights, patients themselves strongly prefer to deliver at home and they often resist referral to the hospital even when their midwife feels it is necessary: "She wanted a home delivery, I was the one who insisted that she go to the hospital." The fact thatDonaClarita'spatientwas reluctant togo to the hospital is not surprising. Indigenous Maya women experience endemic levels of disrespectful and even abusive care in public referral hospitals. This disrespectful care can sometimesbequite overt. For example,most physicians andnurses in public hospitals are not indigenous, and they may directly discriminate against indigenous patients. Similarly, most hospital staff do not speak indigenous Mayan languages, nor do hospitals have language interpreters on staff, so opportunities for misunderstandings and non consented care abound. Finally, institutional factors, such as overcrowding andmedication stockouts, all contribute to clinical uncertainly and instability that dramatically impacts patients' experiences of the hospital environment. Working to reduce maternal mortality is a key global health priority. This is nowhere more the case than in Guatemala, whichhasoneof thehighest ratesofmaternalmortality in Latin America.Guatemala is aCentral American countrywith a large indigenous Maya population, and most of the burden of maternal mortality falls on indigenous women, who are two to three times more likely to die during childbirth. Despite extensive policy efforts by the Guatemalan government and numerous nongovernmental organizations, most of the indigenous women in rural Guatemala continue to deliver in the home, under the care of lay midwives like Dona Clarita. High rates of maternal mortality and late stage presentations of emergency birthing complications to emergency departments are a common source of frustration for providers working in district health centers and regional referral hospitals. Given the widespread home birth rates, it is common for providers in these centers and hospitals to lay most of the blame on the lay midwives. For example, a medical colleague from a busy district hospital recently told us, "If lay midwives didn't exist, rural indigenous women would come to the hospitals to give birth. That would be the best way to decrease maternal mortality in the country." However, in our view, combatting maternal mortality in Guatemala will require willingness tomove past the urge to lay blame, and insteadgrapple seriouslywith the challengeposed to usbyDonaClarita'spatient.Why is it that so few indigenous women are willing to deliver in a facility, even when such a delivery is clearly indicated? And what can we do about it? Importantly, the GuatemalanMinistry of Health increasingly recognizes the importance of these questions and is beginning to address the need to change hospital culture and clinical policies to make obstetrical care for indigenous women more respectful and less frightening. For example, the recent Ley Para la Maternidad Saludable (Healthy Maternity Law) calls for cost reforms, better access to free medications, and respect for intercultural differences. However, there is an important gap between the on paper provisions of this law and reality, as few elements of the law have been implemented in any of Guatemala's hospitals. For example, the law allows midwives or familymembers to accompanypatientswithin the hospital environment. However, most hospitals continue to prohibit the entrance of midwives. Health care workers say this is because they lack the resources and the hospitals are too crowded to comply with the law. "We can't let midwives come in with their patients because we are too crowded!" and "We have asked the authorities to give us more resources to give better attention, but we haven't had anything." At Maya Health Alliance, we are collaborating with a group of 41 lay midwives ~1,000 births/year) and the regional referral hospital in the Chimaltenango department of central Guatemala, working to find answers to these important questions. Recognizing that lay midwives have little formal support and often encounter significant resistance from patients and families themselves when referrals are needed, we have begun a simple mobile phone application to guide midwives through emergency checklists and to connect them, 24hours a day, to an on call medical team, which can help them make emergency decisions. We are also collaborating with the hospital to deploy a team of care navigators. Care navigators are indigenous women who received training from our staff on how to navigate emergency situations andhospital culture.Whena laymidwife decides that an emergency referral is needed, shecan activate a care navigator, who will then take charge of the referral. This Address correspondence to Peter Rohloff, Wuqu' Kawoq, Maya Health Alliance, 2 Calle 5 43, Zona 1, Santiago Sacatepequez, Guatemala, Central America 03006. E mail: peter@wuqukawoq.org
The American journal of tropical medicine and hygiene