Care Seeking & Childbirth Lit Review 1 Mayo

7/29/2019 Care Seeking & Childbirth Lit Review 1 Mayo

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CARE SEEKING AND CHILDBIRTH IN RURAL GUATEMALA

LITERATURE REVIEW

Sandra Saenz de Tejada and Patricia De La Roca

April 2011

This literature review seeks to address three main topics: i) midwives care practices, ii)womens care seeking behavior and iii) past efforts to integrate TBA into the health system.

Gaps in knowledge are addressed as concluding remarks. An extensive appendix is attached,

which list all documents reviewed and includes a short description of each (methodology,

place of study, authors conclusions and reviewers observations). Most of the documents

reviewed belong to the social sciences, tend to be qualitative and community based.

Documents were gleaned from a variety of sources: personal collection, on-line medical

libraries (WHOs HINARI) and recent publications from the Ministry of Health. Unpublished,

grey documents proved difficult to access. Instead brief reports about specific projects (most

of these funded by USAID) were found on-line in the USAID DEC collection, as well those of

JHPIEGO, Population Council and Calidad en Salud.

Midwives care practices

As depicted in the ethnographic literature, the most frequently reported pathways to

becoming a midwife (comadronas in Spanish, ilonel alomin Kiche or ilonel iyom in Kaqchikel)

are through a divine calling, but also by heredity, an emergency, recruitment to the role either

through apprenticeship and, most recently, through community elections motivated by the

health services. While each community has its own established norms and criteria for

legitimating midwives, these systems are not static and are rapidly changing in response to

both internal pressures and alternative models of midwifery. Traditionally midwives were

born, not made, and if the woman failed to interpret divinatory signs or rejected the vocation,

she was prone to be stricken with a serious illness or malaise that were only overcome when

she accepted her destiny to serve as a midwife. In some areas there is a decline in the number

of those women accepting the position, and in some communities most of the younger

midwives have been directly recruited by biomedical health providers (both by the MOH and

private institutions), thus foregoing her nawal, the divine calling. According to some sources,

older midwives explain that the main reason women refuse the position is due to their


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husbands objections, given that the position offers little pay and entails obligations that leads

to neglect their household chores.

Prenatal care begins usually in the second semester, when the pregnant woman often seeks

her familys trusted midwife. Visits are not regularly scheduled but negotiated between the

midwife, her patient and her family. One of the most central practices identified in theethnographic literature is the practice ofprenatal massage through which the midwives

knowledge is embodied. Through massages (sobadas in Spanish), midwives are able to

determine fetal size and age and if the fetus is determined to be malpositioned, midwives are

able to perform external cephalic versions, repositioning the fetus through abdominal

massage. In addition, prenatal exams serve for social interactions between the midwife and

her patients in which trust, rituals, and the cultural meaning surrounding reproduction are

passed on along with pragmatic advice. Increasingly, notwithstanding, midwives are referring

their patients to the nearest health posts, as the health systems aims to increase prenatal

visits. These visits, however, are not substituting the midwives prenatal exams, but

supplementing them. In some areas, like Solol and San Juan Ostuncalco, prenatal exams take

place inside the tuj or steam house (temascalin Spanish).

Midwives are called whenever labor starts. Often, delivery takes place in kitchen and in the

presence of the womans family, specially her mother, mother-in-law and husband. Squatting

is the preferred position for delivery. Right after birth, the midwife provides an abdominal

massage to help the expulsion of the placenta, which is later burned. The umbilical cord is cut

once it stops pulsating and is disposed of in the kitchen or in the yard, depending on the childs

gender; these rituals, however, are not practiced systematically. The new mother is swaddled

in blankets and often placed close to the hearth, as the body is perceived to be prone to catch

cold, which is associated to long-term illnesses. The midwife provides several visits for a few

days (actual number of days vary widely), providing more abdominal massages as a means to

to help the uterus return to its place and avoid varicose veins. She will then place a tight band

around the womans belly, which is worn for around a month, until the uterus is believed to

have regained its place. Traditionally, midwives provided care for the new mother and child

for around a fortnight, sometimes including light housework and the provision of clean bed

sheets but in many places this is no longer observed, and some women report of only one or

two post-natal visits.

Many midwives are also healers, attending mostly children but also adults. Often they treat

mostly cultural-bound illnesses, but their breath of action can be much wider.

While all Maya midwives come from a shared tradition, they certainly are not a homogeneous

group. There seems to be three factors that explain their adhesion (or departure) to tradition:

their age (older being more traditional), their religion (Catholic more traditional than

Protestant) and their training (those receiving biomedical training less traditional, those that

have learned from other TBA or through their own experience more traditional).

While most TBA will say they do not deliver children for the money but because they have

received the gift to do it, they are paid for their services. Notwithstanding, there is little

information regarding their payment, which may vary according to the babys sex, the


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midwifes reputation, and the difficulty of the labor and delivery. Usually there is a fixed

amount for all their work, which is paid until the baby is born. Some midwives report that

some families claim utter poverty and do not pay them the agreed amount. In any case, the

cost of their services is not unreasonable (recent studies give a range of Q100-300).

Care seeking behavior: Why do indigenous women underutilize the

available health services?

Many studies have dealt with this topic. There are two main groups of explanatory factors:

those related to the demand for health services and those related to its supply. The first group

of factors is are related to the individual woman (age, education, life-style, etc.), the

characteristics of their homes (socio-economic status, civil status, etc.) and those related to

their communities (cultural norms, proximity to urban areas, geography, availability of roads

and other services, etc.). There is ample evidence that culture and social norms have an effect,not only on the utilization of health services but also on the recognition of signs and symptoms

and the normative care during pregnancy, delivery and post-partum. There is also evidence

that physical access to health services and associated economic cost (including transportation)

might be formidable barriers for seeking health care. This review focuses mostly in those

cultural factors that affect care seeking.

a) The clash of different medical traditions. Several documents cited that given that

biomedicine and traditional medicine have different Weltanschau they inevitable collide. The

clash, however, is only apparent and conceals a larger disagreement: that of the hegemonic

Ladino culture that undermines everything Indian as backward and plain wrong. In addition,the local biomedical culture is hegemonic and authoritarian, with little tolerance to other

voices. This leads to an overt discrimination towards indigenous patients, the systematic

undermining of their medical traditions and providers (particularly midwives), which reinforces

the feelings among users that biomedicine is truly incompatible with their own culture. The

literature is rich with details of how these attitudes act as a formidable obstacle for care.

There are multiple examples of womens complaints about abusive and discriminatory

treatment, indigenous nurses that refuse to speak the local Maya language, utter disregard for

communicating to the families the status of the woman, etc. In addition, in a multivariate

study it was found that among indigenous women, past negative experiences with public

health services are more inclined to seek the services of a midwife rather than those of

medical doctors and nurses.

b) Understanding of the nature of the obstetrical problem. In several studies it has been

shown indigenous reproductive behavior is influenced by cultural norms and expectations, and

closely linked to female prestige. Both midwives and their clients consider labor a natural and

predictable process, and obstetric risk is greatly underestimated. Complications are often

understood as an illness that the woman already had or consequences of social problems.

Often, rather than linking physiological determinants to birthing problems, both women and

midwives tend to associate birthing problems with social difficulties, such as fights with the in-laws during pregnancy, husbands who do not take care of their pregnant and the womans


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own behavior (drinking, being careless with her diet, carrying on heavy workloads, etc.).

Midwives course of action, thus, include attempts to restore the lost balance. By prioritizing

social factors over physiology, a woman who has taken the culturally-sanctioned care of

herself during pregnancy can feel she can influence the odds of surviving pregnancy

complications, which also provides her with a sense of security. In addition, multivariate

studies have found that that in rural Guatemala, even women who experienced a serious

complication during pregnancy were more likely to seek care from midwives than from a

biomedical provider. It would seem that in situations of risks, the cultural norm is still to

deliver at home with the support of family and the trusted midwife.

c) Womens position and autonomy. Indigenous women often do not have the freedom to

choose by themselves where and with whom to give birth. Particularly in rural areas, they are

far from autonomy and it has been documented that their families often do not provide the

culturally-mandated care they need during pregnancy and child birth. Womens position is

often subordinated to their husbands and their in-laws and when it comes to decide about

health care, those deciding are not necessarily those that have the birthing woman in highest

regard. In Guatemala, it has been found that married rural women who reported greater

household decision-making power used biomedical services during pregnancy more often than

those who reported less autonomy.

A few studies have specifically focused on husbands role in health care decision-taking. In a

JHPIEGO study it was found that husbands were the principal decision-makers in getting their

wives to a biomedical care setting for obstetric emergencies, and observed that mothers-in-

law and traditional birth attendants also had considerable influence in the negotiation

surrounding whether to seek biomedical. The studies also notice heterogeneity among the

relative decision making of rural couples: in those with both partners educated and in couples

in which women work for pay, both partners were significantly more likely to report that both

of them participate in the final decisions than was the case in couples without education or in

which the wife did not work for pay. Another study also found that men are still generally

considered the main decision-makers, especially when the decision involves expenses.

d) Fundamentalism. For some women in certain villages, religion may pose a formidable

obstacle for seeking emergency care. In more than a few Evangelical churches, the pastor

advises against or outright forbids parishioners from seeking outside help and requests to seek

only religious solutions. Birth becomes a test of faith for the woman and it is expected thatbeing pious is a guarantee of having no difficulties. Among some fundamentalists, the best

way to solve physiological symptoms is through prayer and going to the hospital is an

admission to a lack of faith.

e) Cultural interpretation of the hot-cold balance. The idea ofduality is pervasive in

traditional Maya medicine. It is well known that according to lay (both Maya and Ladino)

ethnophysiology, cold is a feared etiological agent. Postpartum is perceived as a physiological

state that requires extreme caution as cold is prone to enter her body and produce long-term

disease. Midwives share this view and they know how to keep the woman well protected from

this feared element. Hospitals, however, disregard such subtleties and not only do not offer

anything hot for her to drink, but rather force women to eat cold foods and even take cold


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showers. Many women (even urban Ladinas) are truly terrified the consequences these

behaviors might bring.

f) Local interpretation of hospital procedures. In lay Spanish, la operacin (the same word is

often also used in Kiche and in Kaqchikel), is used to describe both a cesarean section and a

tubal ligation. While in a general level these are understood as different procedures, in

everyday life people tend to collapse the two, creating ambiguity and confusion concerning

how a c-section affects fertility. The MOH norm that women with previous c-sections need to

deliver in the hospital supports the interpretation that going to the hospital makes subsequent

pregnancies and deliveries more difficult. In addition to the fears and actual difficulties of

taking a woman to the hospital, given that many rural families expect to have many children

the decision to take the woman to the hospital can be further delayed, as this might jeopardize

her future fertility.

In addition, due to the chronic shortage of blood in most Guatemalan hospitals, families are

asked to donate and replace the blood used in transfusions. Most indigenous people,

however, are completely opposed to donating blood, as it is believed that blood is a non-

renewable resource and that removal of blood is a debilitating procedure. A case history from

Solol was reviewed where the family told everyone in their village not to go to the hospital

because the staff would threaten and try to steal your blood. Despite the fact that the woman

and her baby were saved because of the blood transfusion, for the family, the visit to the

hospital was a disaster. Clearly, culturally-appropriate communication could prevent these

misunderstandings.

Efforts to integrate midwives into the public health system

For heuristic purposes past experiences with midwives will be grouped in three: interventions

that have focused mostly on training, those that have sought to open a place for them among

public hospitals, and those that have sought to provide more culturally-appropriate services

and include midwives a health providers.

Training. MOH began training TBA in 1938 as an effort to reduce maternal and neonatal

morbidity and mortality. There are gaps in the literature and there is little information on how

midwives were trained, contents covered and methods used. Midwives have had to cope with

increasing government regulations, compulsory training and working licence. Up until de mid

1980 training programs seem to have been characterized by vertical approach concerned on

showing the superiority of the biomedical model, were conducted mostly in Spanish and often

were not suitable for a mostly illiterate audience. By the end of the 1980s UNICEF began

providing a more culturally-appropriate training, taking a participative approach, and more

respective of their traditional practices. MotherCare relied on IEC, providing training in the

local languages and even validating the translations of the training sessions. Evaluations of this

project showed that midwives felt motivated to apply their new knowledge. There does not

seem to be a follow-up of the trained midwives and it is not known if the improved practices

proved sustainable or not. In our own ethnographic fieldwork it has not been uncommon to


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hear comments such as before, when X was giving us basic supplies, we had gloves, gauze

pads and even alcohol. Now we ran out and I do not buy them at all.

Part of the success of both UNICEF- and MotherCare-led training has been a more horizontal

rapport between trainers and trainees, use of local language, an effort to avoid imposition of

biomedical norms and providing midwives with the opportunity to learn by sharing their ownexperiences.

Since the signing of the Peace Accords and the implementation of SIAS (now called PEC), the

MOH has continued training midwives. Several documents (written mostly by anthropologists)

have criticized both the methods and the contents of these programs, noting than rather than

educating they are deforming the role and positions of midwives. Of special importance is the

new recruiting methods and strengthening of the biomedical model. Some Maya

organizations have also criticized the programs, arguing against its cultural deformation and

what they see as the commercialization of midwifery (SIAS has encouraged midwives to

charge for their services).

More recently there has been at least to attempts to take training to a different level and

provide a more professional instruction. Calidad en Salud introduced a new figure: the Maya

obstetric nurse. It funded an eight-month training of 88 nurses, gleaned from rural, Maya

communities. These nurses were trained in midwifery but also in traditional Maya culture.

Initial evaluations showed an increase in referral. It is not know how these nurses were later

absorbed in the labor market and if they were effectively able to supervise rural midwives.

The other experience is that of PAHO, who has proposed the creation of professional

midwives. Its methodology includes the legal aspects needed for their integration in the

health services, how to train trainers and continuous M&E.

It needs to be stressed that the MOH is not by far, the only institution training midwives: there

are a myriad of institutions, both local and foreign alternative providing training and support to

midwives.

Midwives and hospitals. The first time midwives were allowed to enter a hospital was at

Solol, but it is not well documented. To date, ten midwives continue working at the hospital,

badly underpaid (Q150/month), and mistreated. The experience at the Hospital de

Quetzaltenango is better documented. This intervention began with the training of hospital

staff, both in standards of care for managing obstetrical and neonatal patients, but also on theneed to being supportive of midwives and their patients. Midwives were encouraged to visit

the hospital and observe the deliveries of their patients. Midwives also received a training

program which focused the identification of high risk obstetrical complications and to transfer

women and infants at risk to the referral hospital in a timely manner. The intervention made a

great impact on the timing and number of referrals (midwives were more likely to refer when

complications were first identified) and there was also an increase in patient satisfaction.

Main lessons learned from this experience was the need to provide the rural population with

continuous care for pregnancy, delivery and post-partum, an adequate link between all levels

of health services and a reliable referral system. In addition, it showed the need to train

health providers and improve their perceptions of midwives and that care should be given that


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the strengthening the use of biomedical services stems from a more aware demand and not

the result of an imposition.

Midwives and intercultural health services. More recently there have been several attempts

to create culturally-appropriate health services. One of the earliest was that ofPIES, inChiquirichapa, Quetzaltenango, in the late 1990s. In this small town a clinic was founded that

proposed to provide affordable care that combined traditional Maya practices and

biomedicine. The clinic was open 24/7 and was staffed by seven trained midwives, one

physician and a dentist. All midwives came from the municipality and were trained for two

years, including rounds at the Hospital de Quetzaltenango. Midwives attended all births,

backed up, when needed by the physician. Mothers and other female relatives were allowed

to accompany the patient.

Around the same time, the Ixmucan clinic in Antigua (Midwives for midwives) began to offer

an alternative birthing center and a training program to local midwives, provided by

professional midwives (mostly expatriates). Trained midwives become certified and are

allowed to bring their patients to the clinic, which seeks to bear a resemblance of a traditional

environment. Traditional infusions are available and following cultural preferences, birthing

rooms are kept warm.

Medicus Mundi has implemented an intercultural health model, tested for over two years in

two municipios, Nahual and San Juan Ostuncalco. They implemented 10 health posts (Casas

de Salud Comunitarias), trained 10 health teams (28 workers) and kept a close relationship

with 168 folk practitioners, including 89 midwives, to whom they referred different cases.

From their reports, it is not clear if any training was provided to midwives. Their model, called

MIS (Modelo Incluyente de Salud) is currently under negotiation with the MOH for its

implementation on a wider area.

The MOH has launched an initiative that seeks to involve midwives into the health services

(notably in the new birthing facilities built in some health centers, CAP). It has developed a set

of culturally appropriate norms, that include the availability of bilingual health personnel,

raising awareness among health workers about the pivotal role midwifes perform in the rural

areas, and the flexibility for women who choose to deliver following tradition: vertical birth,

hot infusion, presence of one family member, and allowing the family to decide how to dispose

the placenta. The norms are not clear regarding midwives, as they are only mentioned as one

of the possible companion that the patient may choose. Advances in the implementations of

these norms in five departamentos were recently addressed. As described in the report,

health services (2 and 3 level) have become more open (or at least less hostile) to midwives,

who nevertheless are not allow to attend births and whose main role is to bring both

emotional and physical support to birthing patients. It was found that a few health centers

actually hire midwives, but only in one (San Pedro Sacatepequez, San Marcos) they are allowed

to attend births. The report shows that when asked, health providers tend to list the norms asif they actually took place in their premises. But when the same issues are asked to women


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and midwives, it becomes clear that advances are very modest. Most premises have finally

hired bilingual personnel, hostility towards midwives has decreased (but it is still felt by both

midwives and their clients) and there has been a noted rise in institutional birth. Only one of

the 15 centers provides warm showers and none offers culturally-appropriate infusions.

Midwives, in general, were pleased to have been allowed into the birthing room (although in

some health centers they are still not tolerated), but wish they were given the opportunity to

attend births. They also complained about the rude treatment of the staff and continue to

demand a more humane treatment of their clients.

Gaps in knowledge

There are very few evaluation of most interventions No follow-up of past projects: difficult to know if any of the introduced changes had any

sustainability

Given the dearth of reports, there is a need to interview project personnel There are few, if any, detailed reports about midwives own views about the (compulsory)

training they receive from the MOH or their perceptions on recent changes, brought by

SIA/PEC and more recently by the so-called culturally appropriate services .

No information about costs and implementation of culturally appropriate birthing centers,such as those in PIES or MIS, even those of MOH

Need to better address what women perceive as quality care in public health facilities.Quality of perceived to be better at private clinics. What exactly do they like?

How do all referral systems affect midwives personal economy? If they charge for theirservices only after delivering the babies, why would they refer apparently normal,

uncomplicated pregnant women to the public health services?

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