The training and practice of traditional birth attendants in Guatemala

A literature review interviews field visits and a review by an informal working group of experts involved in midwife activities were the basis for this comprehensive evaluation of midwifery practices and training programs among the Mayan population of Guatemala. Over 80% of births are attended by traditional birth attendants in highland Guatemala where the infant mortality rate is estimated at 120/1000 live births or higher. The midwife will continue to be the key element in efforts to reduce infant and maternal mortality in the region for the foreseeable future. The Guatemalan government began training programs for midwives as early as 1955 and training has been supported in the past UNICEF CARE the UN Fund for Population Activities and the US Agency for International Development. The present Ministry of Health training program covers 9 subject areas in 15 8-hour days. Around 70% of Guatemalas estimated 20000 midwives have been trained. The authors of the report conclude that application of a western urban hospital- based birthing model to traditional birth attendant training has been inappropriate and damaging. The 15 day training course is too complex and theoretical for the midwives who are mostly illiterate older rural women. Poor interpersonal relations between some Ministry of Health officials and the greater experience of many midwives than of the nurses presumably teaching them are other constraints. The training courses have had a positive impact or reducing use of alcohol by traditional birth attendants and women in labor and on having the women push too early in labor. Hand washing high risk screening and referral nutrition counselling prenatal referral for tetanus toxoid vaccination and improved attention to the newborn immediately after delivery are beneficial new practices introduced in training programs. 3 positive traditional practices have unfortunately been discouraged by training programs including the upright delivery position external version in cases of malpresentation of the fetus and cauterization of the cord. Some mildly beneficial or neutral practices have been discouraged somewhat in training programs including traditional sweat baths medicinal herbs pre- and postnatal massages and uterine binding. The widespread practice of giving intramuscular injections of oxytocin to stimulate uterine contractions is very harmful and probably responsible for a significant increase in intrauterine fetal death. Recommendations of previous evaluations of traditional birth attendants in Guatemala have gone unheeded and it is suggested that attention be given to the process as well as the content of change. Specific recommendations are made in the areas of institutional development training health education interagency coordination research and evaluation and a residual category encompassing replacement of UNICEF delivery kits with local alternatives and curbing access to oxytocin.