Renegade Scissors, Duct Tape, and Comedronas in Totonicopan

“If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”

-       Nelson Mandela

There were languages aplenty in the lecture hall at the Hospital Nacional in Totonicapan today for our first course for the midwives—between English, Spanish, and K’iche’, the process of communication was sometimes challenging, sometimes lengthy, and always intentional. Yet, strikingly, a common language emerged, which transcended national, cultural, and socioeconomic bounds. The love of obstetrics and the commitment to enabling safe childbirth for mothers and babies was obvious among the women gathered in the room today. 

Some had been delivering babies for over 35 years, others were brand new to midwifery and had yet to see their first birth. One had traveled 3 hours by bus to be with us for the day. All of them were undeniably dedicated to their profession and were eager to learn and share their experiences. 

In our small group sessions with the mannequins, one of the most seasoned midwives demonstrated for us what she would do when she attended a birth. The joy in her face, her eyes twinkling as she swaddled the plastic baby and meticulously cleaned off the mannequin—it was unsurprising that she drew a crowd of her peers, who gathered to watch her work and hear her share her expertise. 

In the end, I suspect that we learned much more from these resilient, passionate, and wise women than they did from us today. But as hopefully the first step in creating a lasting relationship between these midwives and the physicians and nurses in Totonicapan, this was an incredible opportunity to meet one another, break bread together, and get a glimpse in to each others’ worlds. That they were able to share with us their beliefs, concerns, and needs will be hugely helpful in determining how to design future programs to be most useful for their practices.

It is hard to put into words how humbling and inspiring it is to have spent the day in such amazing company, and also to be reminded of just how ancient and beautiful an art it is to bring life into the world--something we have practiced since the dawn of humanity, yet that we can continue to learn more about everyday. 

--Candace Pau

What a day! An early start – Chapin breakfast with frijoles, platanos, tortillas and salsa verde. Que rico!

Sarah M. shared information from an interesting article she found on lay midwives in Guatemala. The maternal mortality here is 140 per 100,000 pregnancies, which is 5 times higher than the US, but really, Israel and Belarus are the best places to be pregnant (MM 1-2/100,000)!

70% of births here are attended by lay midwives, and occur at home. Instead of trying to suppress midwifery practice, the government has instead tried to improve outcomes by increasing the capacity of the midwives through certification and ongoing education! The midwives usually speak one of the 24 different Mayan languages, often no Spanish, which complicates the government efforts for standardized education.

Dr. Mercedes arranged a course with a group of midwives who have brought patients to the hospital before, and went through an application process. When we met the women, we were enchanted by the beautiful embroidered huipiles they wore, the years of experience they carry, and the dedication they demonstrate by coming all the way to Totonicapan from their villages: Momostenango, Santa Maria Chiquimula, and Canton Poxlaqui to join with us in the class. Each introduced themselves formally with their full names, their region, an expression of gratitude for our being there and their eagerness to learn.

They wanted to learn about prenatal care, were concerned about the poor nutrition of their Moms, about their observation over the years of increasingly difficult labors and complicated pregnancies. They wanted to learn about causes of hypertensive disorders of pregnancy, late pregnancy bleeding and newborn anomalies. They also want to bring this information to their colleagues that don’t have the capacity to come to trainings like this.

These are women that are more than willing to bring their patients to the hospital when complications arise, but also face significant barriers in doing so. Logistical barriers seem obvious, but even moreso, they describe patient resistance. The women want to deliver in their homes, in whatever position feels right to them, with all their people around, and they don’t want vaginal exams and episiotomies.

The midwives shared stories with us about their experiences: Dominga was probably in her 30s when she got her calling to midwifery. It happened in a  dream where a long haired woman in a long white gown insisted that Dominga attend her labor, even though she had no experience in this. This woman talked her through every step, teaching her everything she needed to know, from how to massage and position her, to how to manage the placenta. Dominga awoke disconcerted, but 3 days later put all this information to use when a neighbor asked for her help in an actual delivery. She’s been a midwife ever since.

We learned about the herbal baths they prepare on the first postpartum day that brings in the milk, the cleansings in the temezcal, how they help Mom to nurse, etc.

We were especially impressed with their amazing palpatory skills: one woman diagnosed triplets with her hands, later confirmed by ultrasound; another described diagnosing oligohydramnios; others found malpresentations such as footling and frank breech. These women are on the frontlines, they provide prenatal and pediatric care in addition to attending deliveries, and even field questions about general medical care. No wonder they are anxious to increase their knowledge base.

The midwives that were present today feel a sense of obligation to share the information they have with their colleagues who can’t access the hospital. Some have over 3 decades of experience. They care deeply about their communities, love what they do, love the Moms and babies (even cuddling the mannequin babe and treating it tenderly!), and love, and are proud of, the traditions that they continue. We all felt inspired by these women and hope to return to work with them more in the future.

This training was the first of its kind. It wasn’t sponsored by the government, but by the Totonicapan Hospital. Dr. Merecedes is dedicated to serving this community, much like her older sister who is a radiologist and her incredible mother, Norma.  Norma is a Family Physician who trained in Albequerque and returned to her home country to teach and practice medicine.  She continues to teach at the University and brought ALSO here in the first place in 2004 after learning about it in Albequerque and helping to introduce it to Ecuador!  Her vision is far-reaching--ALSO is well-established at the medical school in Xela, and she is now considering ways to sustainably teach comodronas.   She welcomed our entire group over to meet more family and enjoy a delicious pepian – traditional Guatemalan chicken stew. And maybe a michelata or two.  

--Audra Lehman

Introductions--THANK YOU Isabella, for serving as our interpreter much of the day!

Providentially, Rebecca's scissors made it through security…AND she thought that "having duct tape might be a good idea" on the trip.  Well, both came in handy when we learned that the comodronas wanted to learn about exams.  A few snips here and lots of wrapping…and we ended up with great ad lib teaching models (see Audra demo).

Audra and Allison set up for the hands-on practice.  

Isabella in action!  The comodronas were eager for the opportunity to share their knowledge and demonstrate their skills.

Sarah M is fully engaged as she helps two comodronas deliver this baby (mannequin).  

Rebecca and a comodrona share a happy delivery. 

The comodronas--who serve in different areas--teach one another.  Love this collaboration.

Las manos de vida--these are some of the hands that welcome life into the Totonicapan community.  The stories they tell...

Dr. Mercedes gave us a tour of the hospital--here's  view of the delivery room.

A shout out to Harrison, who asked about the Guatemalan skies…brilliant blue with dramatic clouds.

Keep looking upward. --sj