Professional Documents
Culture Documents
Midwifery
journal homepage: www.elsevier.com/midw
a r t i c l e i n f o
abstract
Article history:
Received 29 January 2012
Received in revised form
13 July 2012
Accepted 20 August 2012
Objectives: to examine the present-day knowledge formation and practice of indigenous Kaqchikel-speaking
midwives, with special attention to their interactions with the Guatemalan medical community, training
models, and allopathic knowledge in general.
Design/participants: a qualitative study consisting of participant-observation in lay midwife training programs; in-depth interviews with 44 practicing indigenous midwives; and three focus groups with midwives
of a local non-governmental organization.
Setting: Kaqchikel Maya-speaking communities in the Guatemalan highlands.
Findings: the cumulative undermining effects of marginalization, cultural and linguistic barriers, and poorly
designed training programs contribute to the failure of lay midwife-focused initiatives in Guatemala to
improve maternalchild health outcomes. Furthermore, in contrast to prevailing assumptions, Kaqchikel
Maya midwives integrate allopathic obstetrical knowledge into their practice at a high level.
Conclusions and implications: as indigenous midwives in Guatemala will continue to provide a large fraction
of the obstetrical services among rural populations for many years to come, maternalchild policy initiatives
must take into account that: (1) Guatemalan midwife training programs can be signicantly improved when
instruction occurs in local languages, such as Kaqchikel, and (2) indigenous midwives increasing allopathic
repertoire may serve as a productive ground for synergistic collaborations between lay midwives and the
allopathic medical community.
& 2012 Elsevier Ltd. All rights reserved.
Keywords:
Guatemala
Lay midwifery
Traditional birth attendant
Indigenous health
Introduction
Guatemala is one of the most impoverished nations in Latin
America, performing consistently poorly on nearly all indicators of
health, social, and economic development (MSPAS et al., 2009; UNDP,
2009). Furthermore, according to recent governmental surveys, 38%
of the population of Guatemala self-identies as indigenous Maya
(MSPAS et al., 2009), a number which grossly underestimates the true
proportion of the population which preserves at least some components of Maya ethnic identity, such as the use of traditional woven
clothing or the speaking of 21 distinct Mayan languages (Richards,
2003). This indigenous population shoulders the brunt of the
n
Corresponding author at: Brigham and Womens Hospital, Dept of Medicine,
75 Francis Street, Boston, MA, USA.
E-mail address: peter@wuqukawoq.org (P. Rohloff).
countrys burden of poverty, with well-documented and wide disparities in health and economic outcomes (Gragnolati and Marini,
2003; Kestler, 1995; MSPAS et al., 2009).
Since the advent of the World Health Organizations Safe Motherhood Initiative in 1987, global health policy has focused on measurable improvements in maternalchild health outcomes in the worlds
poorest countries, including Guatemala. Notwithstanding, Guatemala
still has one of the highest maternal mortality ratios (MMR) in the
region; ofcial statistics place the current MMR at 110 per 100,000
live births (WHO et al., 2008). Especially outside the major metropolitan areas, as many as 70% of births in Guatemala occur in the
home, with lay midwives in attendance. The remainder of births
occur in what the Ministry of Health (MOH) calls a health-care
establishment, a term which encompasses a diverse array of clinical
settings, including private clinics, local Health Posts, regional Maternity Centres, and departmental or national hospitals (MSPAS et al.,
0266-6138/$ - see front matter & 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.midw.2012.08.011
Please cite this article as: Chary, A., et al., The changing role of indigenous lay midwives in Guatemala: New frameworks for analysis.
Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2012.08.011
Methods
This investigation was commissioned and sponsored by Wuqu
Kawoq (http://www.wuqukawoq.org), a non-prot organization
working to develop rural health-care services in Guatemala, as
part of a situation and needs assessment prior to the development
of a new midwife training protocol. In addition to their home
institutions, all authors are also current staff members or volunteers at Wuqu Kawoq. The research protocol was reviewed Wuqu
Kawoqs own IRB and by Partners Healthcare (home institutional
IRB for PR) and granted exemption under 45 CFR 46.101(b)(2)
(research involving the use of educational tests, survey procedures,
interview procedures or observation of public behaviour).
We present data derived from interactions with Kaqchikelspeaking midwives from the departments of Chimaltenango and
Sacatepequez. These two departments are located in the central
Guatemalan highlands, a short distance west of the capital city
down the Pan-American Highway. Both departments contain
medium-sized urban centres of 30,00060,000 people, such as
the cities of Antigua (Sacatepequez) and Chimaltenango (Chimaltenango), which serve as important sites of tourism and business
and are typically dominated by non-indigenous political interests.
However, outside these centres, the bulk of the population is
indigenous, and traditional agricultural lifestyles are still common, as is the wearing of indigenous clothing and the use of
Kaqchikel Maya (spoken by more than 500,000 individuals) in
everyday speech.
Most of our research interactions occurred in 20082009 as a
series of in-depth interviews with 44 practicing midwives who were
recruited using snowball sampling (Coleman, 1958). These interviews focused on: educational background and nature of professional
formation in midwifery; individual practice characteristics, such as
use of medicinal plants or pharmaceuticals; experiences interacting
with the Guatemalan medical community; experiences attending
various types of midwife training sessions; and knowledge of best
practices in midwifery (e.g., hospital referral for prior caesarean
Please cite this article as: Chary, A., et al., The changing role of indigenous lay midwives in Guatemala: New frameworks for analysis.
Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2012.08.011
section). Interviews were about 1 hr in length, were largely conducted in Kaqchikel, and were recorded to facilitate analysis.
In addition to the in-depth interviews, over the same time period,
we conducted participant observations, consisting of attendance
approximately once monthly at midwife training sessions. Sessions
typically lasted 24 hrs and consisted of 2040 participants and 13
facilitators. We conducted observations in two training environments; the rst were training sessions offered by the MOH, while the
second were trainings offered by a NGO that was begun and led by a
self-organized group of local midwives. In these sessions, we focused
on observing: interactions between participants and facilitators;
pedagogical methodology; and language use and comprehension
among participants. MOH sessions were typically in Spanish,
although small talk between participants was generally in Kaqchikel.
The NGO sessions were conducted in Kaqchikel. Participant observation and focus group sessions were not recorded; rather, extensive
note taking before and immediately after each session was used to
document observations.
We also conducted three focus groups in Kaqchikel with the
midwife leadership of the above-mentioned NGO. These groups
consisted of 510 participants, and conversation focused on: the
role of language and culture in the groups work; interactions
with the Guatemalan medical community; and conceptions of
midwife professionalization. Focus groups were not recorded
but, rather, documented with extensive note taking. They were
also supplemented by recorded interviews in Kaqchikel of
510 mins in length in which 9 staff and board members were
asked to give their narrative assessment of the origins and
philosophy of their organization.
Findings
Basic characteristics of in-depth interview participants
Summary data derived from the 44 in-depth interviews are
summarized in Table 1. The mean age of participants was 54 years.
The majority of participants, 59%, were monolingual in Kaqchikel,
whereas the remainder were bilingual; there were no participants
monolingual in Spanish only. The formal educational level of
participants was exceedingly low, with a mean of only 1.3 years of
primary school education, and a full 63% of participants had never
attended primary school. On average, participants had practiced
midwifery for 21 years, and the average patient volume was around
5 patients per month, although there was considerable variation for
both of these parameters.
Midwife training programs: language barriers
Among in-depth interview participants 86% had participated
in MOH midwife training sessions and 100% had participated in
Table 1
Basic characteristics of in-depth interview participants (n 44).
Characteristic
Mean age (years7 SD)
547 11
Language preference (%)
Kaqchikel only
59
Spanish only
0
Both
41
Mean education (years
1.37 2.3
completed 7SD)
No formal education (%)
63
Mean length of practice (years 7SD) 217 12
Mean patients/month (7 SD)
5.17 6.9
Table 2
Knowledge formation and scope of practice among in-depth
interview participants (n 44).
Characteristic
Knowledge formation (%)
Apprenticeship
MOH training
NGO training
Diving calling
36
86
100
43
77
30
63
100
94
75
91
81
63
47
Please cite this article as: Chary, A., et al., The changing role of indigenous lay midwives in Guatemala: New frameworks for analysis.
Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2012.08.011
Please cite this article as: Chary, A., et al., The changing role of indigenous lay midwives in Guatemala: New frameworks for analysis.
Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2012.08.011
Table 3
Medicine plant use by in-depth interview participants.
Plant name
Chamomile (Matricaria recutita)
St. Johns wort (Hypericum perforatum)
Lavender (Lavandula latifolia)
Mint (Mentha spp.)
Aloe (Aloe vera)
Apasote (Chenopodium ambrosioides)
Wormwood (Artemisia absinthium)
Times mentioned
13
9
5
2
2
1
1
Discussion
In this study we have used qualitative investigative methodology to examine the changing roles of indigenous lay midwives
in Guatemala. We have undertaken this study against an emerging policy background that, in keeping with the directives of the
Safe Motherhood Initiative and the Millennium Development
Goals, has progressively attenuated the role of lay midwives and
other TBAs in the provision of obstetrical services. In Guatemala,
this shift has been justied in large measure by the perceived
failure of lay midwife training programs to impact maternalchild
health outcomes.
However, the assessment that lay midwife training programs
are ineffective deserves a careful root-cause analysis. Extant literature, for example, is replete with examples of poorly designed,
culturally inappropriate midwife training programs (Greenberg,
1982; Kruske and Barclay, 2004; Lang and Elkin, 1997; Maupin,
2008). In this paper, we add new qualitative data focusing specically
on the ways in which language barriers contribute to training
programs low quality. Government health service workers persisted
in their general disregard for indigenous languages and did not
provide training in these languages. As a result, midwives with little
Spanish uency felt demeaned and were unable to comprehend
training materials, an ethnographic insight corroborated by basic
demographic data collected during our in-depth interviews.
The interviews revealed that that, in our sample, the majority of
participants were monolingual in Kaqchikel and possessed, on
average, just over 1 year of formal primary school education. In
contrast, our observations of training sessions in a local midwife-led
NGO had a much different feel. There, trainings were offered in
Kaqchikel and used a more participative pedagogy; as a result,
attendance and satisfaction were much higher. These contrasts
strongly suggest that one major factor in the (in) effectiveness of
indigenous midwife training is insistence on Spanish as a medium of
instruction.
In addition to language and pedagogical barriers in training
sessions, midwives also are marginalized by opposition to their
practice and professional organization by the medical community. For example, observers of midwife training programs over
the last 3 decades have noted that often a disproportionate
amount of training time is devoted to attacking traditional birthing practices (such as the use of medicinal plants, alternative birth
positions, and the sweat bath) rather than to constructive interchange and knowledge acquisition (Cosminsky, 1982; Greenberg,
1982; Hinojosa, 2004; Maupin, 2008). Furthermore, Maupin (2008,
2009, 2011) has elegantly documented the ways in which rural
midwife training paradigms have been used to undermine midwives
broadly as rural health agents. Similarly, in our sample, many informants alleged that midwife trainings were utilized to restrict or
eliminate midwifery practice. Indeed, when the midwife-led NGO
observed in our sample attempted to self-organize and develop its
own culturally and linguistically appropriate trainings, this was
vigorously opposed by local health authorities. While anecdotal, these
incidents suggest that the widespread perception among indigenous
midwives that the broader health community is biased against them
culturally, linguistically, and racially are not unfounded. Doubtlessly,
these biases have greatly impacted the efcacy of midwife training
efforts.
In the nal section of our study, we turn to an analysis of the
process of knowledge acquisition and professional formation
Please cite this article as: Chary, A., et al., The changing role of indigenous lay midwives in Guatemala: New frameworks for analysis.
Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2012.08.011
Conclusions
Driven by a recent policy emphasis that shifts the place of
birth from the home to the hospital, the role of indigenous lay
midwives has increasingly been restricted in Guatemala. Here,
however, we present data demonstrating that justifying this shift
based on the ineffectiveness of lay midwife training classes fails
to take into account the historically low quality and linguistic
inappropriateness of those training programs, as well as the ways
in which midwives remain marginalized and undermined by both
overt racism as well as bias in the allopathic community. Furthermore, we document the ways in which midwives avidly seek out
and acquire allopathic knowledge and incorporate it into their
practice in dynamic and adaptive ways.
These ndings have implications both for future research and
also for policy. From the standpoint of research on midwifery
practice in Guatemala, it is important to recognize the ways in
which an ethnographic focus on the socio-religious and difference
aspects of midwifery contributes to the view among policy makers
that indigenous midwives are untrainable, in large part by neglecting analysis of other elements, such as professional identity and
educational formation. Items like Do you think birth is sacred?
Why? (Walsh, 2006) can be construed as leading questions, in that
Acknowledgements
This work was supported in part by a grant from the Conservation, Food, and Health Foundation (to PR).
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Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2012.08.011