Guest Roast: “Traditional Birth Assistants: Scapegoats or Potential Miracle Workers?”

Thomas Hart has been called ‘a fine example of a “citizen of the world”’* and an expert on traditional Maya practices having lived, worked and studied in Guatemala for the best part of two decades. Thomas is an anthropologist at heart and has consolidated his vast knowledge in his book “The Ancient Spirituality of the Modern Maya”. He works for a British NGO called Health, Poverty, Action and as a guest roaster shares with us some potential solutions to high maternal mortality rates in Guatemala**.

Comadronas, Guatemala’s Traditional Birth Attendants (TBAs), are community midwives who are estimated to deliver up to 90% of births in rural Guatemala. Their relationship with the Ministry of Health has been a complicated one. In many communities, they have been derided by health professionals as uneducated (they sometimes are), illiterate (they sometimes are) and even superstitious (for practicing their own indigenous culture). As such they have served as convenient scapegoats for high maternal mortality rates, which are estimated to be twenty times higher in developing nations (1).

In Guatemala, the maternal mortality rate for indigenous women is still three times higher than for non indigenous women. The causes are well known. For example, when complications are identified during pregnancy, a trip to the nearest hospital can be beyond the means of the family. Whilst the resistance to seeking qualified medical attention is often due to mistrust and lack of confidence in non indigenous providers.

Although perhaps a majority of Guatemala’s population is indigenous, the state has always had a non-indigenous face. During the worst of the civil war which ended in 1996, the most common representative of the state in many rural communities wore the uniform of the military commissioner, effectively empowered with decision of life or death over community members. The brutal anti-insurgency campaign not only left some 200,000 dead, but it led to widespread fear of the state and all it represented for many rural indigenous communities.

Nowadays, democratic reform has “provided” a slew of rights: such as the right to education, health services and justice in the community’s own language. But all too often, these remain nothing more tangible than printed words on paper. A recent report found that in Guatemala’s second city of Quetzaltenango, with a K’iche’ majority, the city’s police force has a single officer who identifies himself as K’iche’. In some health centres, provision of K’iche’ language health service means bringing the cleaner in to sit in on a medical consultation.

And that’s where the TBA comes in. Her role in maternal health goes far beyond simple antenatal care; she visits the mother in her home, and becomes a source of emotional support during and after pregnancy. She speaks to the mother as an equal, having herself faced the same challenges of living in a context where discrimination attacks the indigenous, women, and the poor. Beyond that, in a deeply religious and spiritual society, the comadrona is considered wise and divinely chosen for the job, yielding significant respect and trust which is missing for the formal system in many indigenous Guatemalans’ eyes (2).

Health Poverty Action is a UK-based NGO that works with TBAs not only in Guatemala, but also in Nicaragua, Peru, Africa and Asia. It recognizes their unique position as primary maternal health care providers in communities which state services have yet to reach. And it wants to support their technical training so they can work alongside health professionals to reduce maternal mortality. Training, which, as a study in a community near Lake Atitlan has shown, is culturally appropriate, can lead to significant positive changes in thecomadronas midwifery practices (3).

HPA, in common with other development organizations, recognises the enormous difference that modern safe birthing facilities make to reducing maternal mortality. And that’s why we are pushing Ministries of Health around the world to ensure that birthing facilities are culturally appropriate. They should provide medical attention in the maternal language (by trained indigenous health professionals rather than translators); they should permit the community based TBA to be an integral part of the team (something which the Bolivian government has successfully done); and they should permit cultural practices such as the use of traditional medicine and diet within Ministry of Health facilities, as well as the return of the placenta to the new mother for ritual disposal (something HPA has successfully piloted in Peru).

HPA’s Mothers on the Margins campaign is based on demands made by indigenous communities across the globe for health services which respond to the needs of the community. We’re collecting signatures globally to encourage states to ensure that the services they provide to indigenous women will have the impact in reducing maternal mortality which we all aim for. Sign our petition by going to:

http://www.healthpovertyaction.org/campaigns/mothers-on-the-margins/

What do you think about the prevalence of traditional methods in medical practice? Leave your reply below.

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Notes:

* http://www.johnjmcgraw.com/anthropology/hart.htm

** You can read Thomas’ other blog post for the UK Foreign Commonwealth Office here

1. World Health Organisation (2000)

2  & 3. Walsh L. V. (2006) “Beliefs and Rituals in Traditional Birth Attendant Practice in Guatemala”, Journal of Transcultural Nursing, Vol. 17, No. 2, pp. 148-154.