1. Bridging the Gap Between Traditional and Institutional Medicine: Midwifery in the Rural
Highlands of Guatemala
Lauren E. Brunner
Tulane University School of Public Health and Tropical Medicine
Global Health Systems and Development Department
Spring 2015

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Abstract
The purpose of this public health analysis is to investigate the current role of traditional
midwives, the midwife training system delivered by the Ministry of Health, and the opinions of
key players in the co-functioning health systems concerning the increasing contact between
health professionals and traditional midwives in the western highlands of Guatemala.
This paper explores current approaches to health services delivery in Guatemala: the
formal system, the Ministry of Health, and the traditional health system, midwives. Specifically,
this paper considers the continuing traditional role that midwives play in caring for women and
delivering children in rural areas of Guatemala, and how the work of midwives and formalized
health structures have begun to work in unison. The Ministry of Health in an effort to reduce
maternal and child mortalities, now provides monthly trainings to midwives in order for them to
be certified. This paper describes this current training system and critically evaluates this
certification process. Principal original data employed are first person observations and
transcripts from three groups: midwives from the municipality of Joyabaj, Quiché; Ministry of
Health professionals; and institutions working to bridge the gap between with traditional
midwives and Western health institutions. The principal investigator manually coded the
transcripts, creating categories to compare and contrast answers within and across study groups.
The paper concludes with recommendations on how to improve coordination between the
Ministry of Health and traditional midwives so that they can effectively and jointly pursue
improvements in maternal and child health outcomes in Joyabaj and other comparable
municipalities in rural Guatemala.

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Table of Contents
Abstract........................................................................................................................................... 2
Background and Significance ......................................................................................................... 4
Maternal and Child Health in Guatemala ...................................................................................... 4
Research Questions, Goals, and Objectives.................................................................................... 6
Methods .......................................................................................................................................... 7
Results ............................................................................................................................................ 8
Literature Review and Observations........................................................................................... 8
The Guatemalan Midwife ................................................................................................... 8
Midwife Training Program Observations ........................................................................... 9
Interview Results ...................................................................................................................... 10
Midwives........................................................................................................................... 10
Ministry of Health Personnel............................................................................................ 12
Organizations Working with Midwives............................................................................ 14
Discussion..................................................................................................................................... 16
Conclusions and Recommendations ............................................................................................. 18
Works Cited ................................................................................................................................. 20
Appendices ................................................................................................................................... 22
Interview Questions .................................................................................................................. 22

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Background and Significance
Traditional health systems play a vital role in health service provision, especially for
rural, remote communities. In the western highlands of Guatemala, many individuals face severe
distances to access health services. In addition to the accessibility of health services, culture
plays a principal role in the decision to seek care in these rural communities. In a context
dominated by Mayan culture, local traditional health providers have a longer history and greater
contact with rural populations. Regarding women’s health, the traditional midwife is typically
more familiar and thus garners more trust and respect than the local Ministry of Health service
provider. The presence of the midwife significantly predates the history of the Guatemalan
Ministry of Health, founded in 1969 (MSPAS, 2015), an institution commonly known for
insufficient personnel and infrastructure. Today these two service providers share the mission to
improve maternal and child health, however they address this task with divergent approaches.
This research responds specifically to the maternal and child health landscape in
Guatemala, considering the case of a rural municipality in the western highlands of the country,
known as Joyabaj, Quiché. Through two years of observational experience, literature review, and
in-depth interviews, this investigation provides perspectives from key players in health services
delivery, offering recommendations on how to improve maternal and child health by means of
the traditional midwife. Currently, midwives who seek to be “certified” are required to attend
monthly trainings at the local Ministry of Health service, to learn about health topics pertinent to
their role as midwives. Trainings are integral in the development of both the skills of midwives
and in building trust between midwives and Ministry of Health workers. The effectiveness of this
certification process is considered in this investigation.
Maternal and Child Health in Guatemala
As defined by the World Bank (2013), Guatemala is a lower middle-income country with
a population of 15.47 million, 51 percent of which lives in rural areas. This substantial rural
population presents significant obstacles for the health care system, especially in the western
highlands of Guatemala, a region plagued by poverty and poor health indicators. A resource poor
national Ministry of Health is challenged to reach these small communities located in the
mountains, hours from major roads. Rural populations encounter disproportionately negative
health outcomes due to the socioeconomic status, education, and physical access to quality health
typical of these regions (CESR, 2008). Specifically, Guatemala struggles with negative maternal

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and child health outcomes. Nationwide, Guatemala has a maternal mortality ratio of 140 deaths
per 100,000 live births, marking it as the country with the fourth highest rate of maternal
mortality in the Americas (WHO, 2013). Disparities in income and infrastructure between urban
and rural populations lead to disproportionate reproductive health risks for rural populations.
Furthermore, the indigenous population of Guatemala, approximately 50 percent of the
population, is at even higher risk of complication in childbirth. According to the 2007
Guatemalan national maternal mortality study, 71 percent of maternal mortalities occurred in
indigenous women (SEGEPLAN, 2010).
The present research considers the specific case of the maternal and child health
landscape in Joyabaj, Quiché. The municipality of Joyabaj has a total population of nearly
90,000 inhabitants, 92 percent of which lives in rural communities (MSPAS, 2014).
Additionally, 90 percent of the population is Maya K’iche, the local indigenous ethnic group.
Based on national trends, this largely rural and indigenous population is at high risk for negative
health outcomes. In terms of health services, fourteen medical doctors, ten licensed nurses, and
26 assistant nurses staff the district hospital in Joyabaj. The hospital delivery room has a six
patient capacity and the inpatient gynecology ward an eight patient capacity. Including only the
population of Joyabaj, an average of eight births would be expected per day in the hospital if all
births were institutional (MSPAS, 2014). Moreover, the district hospital not only serves the
population of Joyabaj, but also frequently receives patients from the four neighboring
municipalities who do not have hospitals, causing additional strain on an already overburdened
health facility. Eight rural health posts provide further coverage in the rural communities, but
these facilities offer services only five days a week for eight hours a day providing basic consults
and prenatal consults, vaccinations, growth monitoring, and health education.
The maternal mortality ratio in Joyabaj is greater than the country average; in 2014
Joyabaj had a maternal mortality ratio of 235 maternal deaths per 100,000 live births. While this
ratio varies per year, the last five years reflect an average of 181 deaths per 100,000 live births
(MSPAS, 2010-2014). The biological causes of maternal mortality in this time are
hemorrhaging, sepsis, and preeclampsia, diagnoses largely related to unhygienic birthing
conditions. Beyond biological determinants of mortality, a variety of socio-economic, cultural,
and logistical factors often contribute to maternal mortalities. During maternal mortality analyses
performed by the Ministry of Health, one of four principles is determined the principal factor of

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death. These principles, known as “the four delays”, include: 1) Inability to identify signs of
danger in pregnancy, delivery, post partum, and newborn; 2) Inability to make the decision to
seek out medical attention; 3) Lack of geographical access to health center; and 4) Lack of
adequate medical attention (MSPAS, 2010). These principles, related to both the cultural and
physical context of Joyabaj, affect maternal mortality and reflect the barriers to be addressed by
both institutional and traditional health systems.
In Joyabaj, the traditional midwife plays a fundamental role in both prenatal attention and
deliveries. Hospital statistics declare that midwives attended 64 percent of births in 2014 (a
decrease from 82 percent in 2010) (MSPAS, 2010-2014). Joyabaj has a total of 302 identified
midwives who currently receive monthly trainings at either the district hospital or community
health posts. Ministry of Health personnel facilitate these trainings, teaching nutrition, hygiene,
emergency signs during pregnancy, birth, and after birth, and creating emergency action plans
(MSPAS, 2014). These trainings are typically the only form of formal training midwives receive,
as apprenticeship and hands-on experience are the norm for midwives to learn their trade.
Research Questions, Goals, and Objectives
Taking into account the health statistics, cultural context, and available health services in
Joyabaj, this research seeks an enhanced understanding of opinions and perceptions of key
players in maternal and child health in order to offer meaningful recommendations and
interventions. Primarily, this research asks how the formal and traditional health systems can
work in unison in order to improve maternal and child health in Joyabaj. Consequently, this
investigation has the following research goals:
a. Describe the role of traditional midwives in the landscape of Maternal and Child Health
in rural Guatemala, specifically in the municipality of Joyabaj, El Quiché.
b. Analyze the development and current status of the relationship between the Ministry of
Health and traditional health systems.
c. Investigate how trainings delivered by the Ministry of Health, provided for traditional
midwives, can be improved in order to improve maternal and child health outcomes in
Joyabaj, and other similar municipalities of Guatemala.

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Methods
Both primary and secondary data are employed in the analyses. Methods include a brief
literature review of the history and role of midwives in Guatemala. The principal investigator
also collected primary research data through first-hand observations while working in the
Joyabaj health district for two years. Interviews with midwives from Joyabaj, Ministry of Health
personnel, and key organizations working with midwives additionally provided insight on the
research questions.
The principal investigator spent two years working full time as a health training
facilitator in the Joyabaj district hospital, enabling first hand observations and experience
through the planning and implementation of midwife trainings. After one year of observation, the
investigator designed the research protocol based on initial conclusions on the health topic,
seeking further perspectives from local experts. Interviews obtained perceptions, opinions, and
suggestions directly from key players on how the relationship between health systems can be
strengthened in order to garner improved health outcomes of the population. Questions utilized
in the in-depth interviews are included in the appendix of this paper. These interviews were
structured in order to facilitate qualitative data analysis across participants, but allowed for
follow-up questions relevant to the research. One critical component of the research was a
trained translator who accompanied the principal investigator in order to conduct the interview
with midwives in their native language, Maya K’iché (not fluently spoken by principal
investigator).
Using the database from the Joyabaj district hospital, the principal investigator recruited
midwife participants by generating a list of all current midwives in Joyabaj, and randomly
selected a sample size of 23 midwives. The principal investigator audio taped interviews in the
homes of the midwives, through the assistance of the translator, and a Mayan language
professional later translated and transcribed interviews into Spanish. The principal investigator
then translated transcriptions from Spanish to English for the presentation of results in this
report. Eight Ministry of Health personnel participated in the study all with experience working
with midwives in Joyabaj. The principal investigator conducted and audio taped these interviews
in Spanish and transcribed the responses into English, with the exception of one participant who
did not wish to be audio taped. Three Guatemalan organizations also provided their experiences
and opinions on the research topic. The principal investigator executed and audio taped the

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interviews in Spanish and transcribed the responses into English. After transcribing all
interviews, the principal investigator manually coded responses, creating topic categories to
analyze data results within and amongst groups. These coding categories allowed for summary
results, data analysis, and research conclusions.
Results
Literature Review and Observations
In order to understand the health beliefs and behaviors of the reproductive population in
Joyabaj, it is essential to understand the role of the midwife. A brief review of the literature
about traditional Guatemalan midwives and observational research of the current training system
for midwives provide context to this analysis’s original research.
The Guatemalan Midwife. The midwife is a figure that garners community respect,
holds a wealth of knowledge, and delivers health services for a low cost, especially in rural,
indigenous communities in Guatemala. Midwives in Guatemala have an extensive history
fulfilling their mission, known not only for their principal function in attending the delivery of
newborns, but also for a variety of other diverse functions (Alvarez et al., 2012). The translation
of midwife in the Mayan language K’iché refers to “the woman who cares, watches over,
controls, and treats other women and children” (Alvarez et al., 2012). The other common
translation for midwife in the local language means “grandmother to our children”. The true
traditional midwife is an individual answering a vocational calling given at birth, individuals
born on certain dates of the Mayan calendar have the ability to easily develop the necessary skills
to be a midwife. The Mayan calendar gives each person a “nawal” or spirit animal based on
his/her birth date, which provides an individual certain energy and characteristics that will guide
an individual in his/her life, for example the midwife as a vocational calling (Alvarez et al.,
2012). Typically, the midwife nawal is reserved for females. There are a variety of ways that a
midwife discovers her calling: through recurring dreams, specific visions, serious illness with no
cure, inheritance, or other signs. Furthermore, it is believed that an individual who does not
adhere to his/her given nawal will encounter many illnesses in life. As quoted by a midwife in
the Medicos Descalzos manual, “The pay that we receive for always fulfilling our vocation is our
own health” (Alvarez et al., 2012).
Traditional midwives are a vital component of the Mayan medical system, specifically
for their role attending women during their pregnancy, delivery, and post-partum. This is their

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main demand in the community, and they are generally known for being capable of doing this
job effectively (Gallegos et al., 2003). The concept of paying midwives for their services is
traditionally unnecessary, as midwives perform their given duties “with pleasure”. It is difficult
to generally define the capabilities and limitations of traditional midwives, as this aptitude
depends on how the midwife learned her trade, the amount of experience in deliveries, and
amount of formal training received (Gallegos et al., 2003).
According to the literature, official recognition of the traditional medicine system in
Guatemala is an ongoing process that began when the Peace Accords were signed after the civil
war ended in 1996. Despite the ubiquity of traditional healers and midwives in rural
communities, many Western health professionals are unaware or negative toward the work of the
unofficial health system (Socop, 2007). National indigenous rights laws signed after the 1996
Peace Accords state that all people have the right to prevent and promote health, specifically
naming midwives as key players in population health (Socop, 2007). These codes from the Peace
Accords are key in acknowledging the worth and legitimacy of traditional medicine as a popular
health service provider in Guatemalan. This initiative, known as the “Indigenous Peoples Health
Initiative” not only supports the midwives’ existence, but names them as critical factor in
addressing the health of indigenous populations, who had (and continue to have) a history of
marginalization from health services and disproportionately poor health outcomes (Gallegos,
2011). This initiative prompted radical changes in the Ministry of Health approach to traditional
midwives whose effects are evident in the current day.
Midwife Training Program Observations. The principal researcher gathered
information about the current Ministry of Health midwife training system through two years of
observing, co-planning, and co-facilitating trainings. The midwife training program in the
Joyabaj health district consists of monthly meetings that last between one and three hours and is
facilitated by the professional nurse in charge of the reproductive health program. Additionally,
rural health posts conduct their own trainings for the midwives who live in the neighboring
communities. In the district hospital trainings, the large group of midwives is split into two,
creating two smaller training groups. Notwithstanding, these trainings include as few as 50
midwives and as many as 110 midwife participants who arrive from different communities to
receive their stamp of participation on their midwife certification card. Officially, three

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consecutive months absent from trainings warrants the hospital to withdraw the midwife’s
certification card.
The main goals of trainings are to increase health knowledge and indicate the extent of
the midwife’s capability. Educational topics typically offered in midwife trainings include the
following (based on the 2015 annual training plan): emergency signs in pregnancy, delivery,
post-partum, and in newborns, nutrition, family planning, “the four delays” (determinants of
maternal mortality), emergency action plans, HIV/AIDS, importance of prenatal controls, health
services network, home and personal hygiene, exclusive breastfeeding, and clean and safe births.
The most critical topic, emergency signs, teaches midwives to identify when pregnant women
need to be referred immediately to the hospital. Trainings aim to effectively communicate these
essential knowledge, abilities, and practices to midwives in a way that is comprehendible for the
generally older, illiterate population of midwives.
Interview Results
Across the three participant groups, interview length ranged from 15 minutes to one hour.
A total of 36 individuals participated in the study. Results reported in this section reflect the data
analysis of coded and categorized transcriptions. The principal investigator analyzed codes that
were used to create interview questions, including the categories of professional experiences,
training satisfaction, training improvements, relationship satisfaction, and maternal mortality
prevention.
Midwives. Twenty-three midwives participated in the present research, all female with
an average age of 61 and an average 28 years of experience as midwife. Participant midwives
live an average of 40 minutes in car from the district hospital, with the most distant home located
an hour and a half drive from the urban center. These midwives attended an average of eight
births last year, with the busiest midwife attending 30 births last year. Only one of the
participants spoke Spanish as a primary language, the others participated in their native language
of Maya K’iche with the support of a trained translator. Only one of the 23 participants was
literate.
Participant midwives shared their journeys to becoming midwife, citing reasons
consistent with the literature review: illness, religion, lack of formal service access, and family
tradition. Midwives also shared common practices in the attention they provide for pregnant
women. House visits generally begin when the woman is two to three months pregnant. From

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this point forward, the midwife visits the pregnant woman approximately every two weeks in
order to bathe her, feel the position of the fetus, perform massage treatment, and impart
information pertinent to the pregnancy. Information includes nutrition habits, the importance of
prenatal control, emergency signs of pregnancy, how to take care of one’s health, coming to
terms with domestic conflicts, and in some cases, family planning methods. In the final months
of pregnancy, it is typical for the midwife to visit more frequently, up to every three days, in
order to review the conditions of the patient. Finally, most midwives reported attending births in
the house, although most have at least one or two experiences accompanying the patient to the
hospital in special circumstances. After the delivery, midwives stay in the house a few hours to
bathe the patient, ensure the newborn and mother are stable. The following ten days after birth
the midwife makes daily house visits to ensure the health of the woman and newborn.
Midwives reported that they receive an average stipend of 30 U.S. dollars per patient.
This stipend covers costs of transport, food, and time; midwives would never “charge” since they
are completing a mission given to them by God. Nonetheless, midwives commonly complained
that many families do not adequately thank them for services; despite their many hours spent
walking, hungry, and cold performing their house visits. The other main work “difficulty” is
complicated births that require hospital referrals. This experience is alarming for both the patient
and the midwife, and is often further complicated by family members who oppose referring the
patient to the hospital (a common reality). Additionally, midwives unanimously lamented the
fact that their materials for attending births are very old or nonexistent, explaining that the
Ministry of Health has not recently offered materials to support clean and safe home deliveries.
Birthing kits are yet another cost midwives incur, many are forced to work without adequate
materials due to limited income. Despite these challenges and inconveniences, the midwives are
generally satisfied with their work, happy to fulfill the mission they were given by God, serving
the people of their respective communities.
The participating midwives also shared their experiences with the institutional health
system, through both trainings and hospital visits with their patients. Most participants have had
at least one experience accompanying a patient for a delivery in the hospital, whether planned or
in an emergency. Many participants had agreeable experiences in the hospital, leaving satisfied
with their ability to “help” with the birth, being at the side of the woman as she delivered the
newborn, describing health personnel as “good people”. However, a fair amount also reported

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strongly negative experiences where they were “forced” out of the delivery room and even
“pushed” or yelled at to “get out of the way”. In these cases, the midwives were very upset with
the outcome, expressing their constant concern for the patient and newborn, even inside the walls
of the hospital. In this way, many midwives expressed their desire for increased respect in the
hospital. In regards to trainings, few midwives could remember the exact year in which they
began trainings, but commented generally that they began participating in trainings when they
learned they were mandatory in order to be certified. Overall, midwives like the trainings, and
view them as important, enjoying the opportunity to learn new information and share experiences
with other midwives. They understood that trainings provide advice directly applicable to the
health of their patients. Some even noted that the trainings motivate their work. On the other
hand, some participants recalled being scolded at trainings for poor practices. Finally, some
midwives commented that many topics are too complicated and are not explained fully in
training. Midwives demanded increased respect, decreased discrimination, permission to enter
the hospital, and fewer costs for their work as ways to improve their relationship with the
hospital. The strain, physically and economically, for midwives to report to the hospital each
month was universally expressed. Despite the anecdotal experiences of a few participants, the
general sentiment of midwives is that they have growing trust in the hospital to adequately treat
their patients.
Finally, midwives offered their opinions on the cause of maternal mortalities in Joyabaj
and how to prevent these deaths. Midwives attribute the majority of maternal deaths to patients
who fail to recognize an emergency sign or wait too long to bring the patient to the hospital.
Others explain that improper self-care, nutrition, or other factors during the pregnancy lead to
complications and ultimately death during delivery. A few mentioned religion or domestic unrest
in their explanations. Midwives emphasized almost universally the imperative to send patients to
the hospital for deliveries in the event of a complication or emergency. Furthermore, midwives
shared that they all must follow given protocols and share the information learned in trainings
with their communities and patients in order to continue improving maternal and child health.
Ministry of Health Personnel. Eight Ministry of Health workers participated in the
research, including the director of the midwife branch of reproductive health on the department
level, the director of the district hospital in Joyabaj, the director of health programs in the rural
areas of Joyabaj, the director of the midwife training program in Joyabaj, and other licensed and

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auxiliary nurses from the rural health posts. Participants had an average of over eight years of
experience working in health.
According to the director of the midwife program on the department level, trainings for
traditional midwives have existed for decades, but they became mandatory for midwife
certification after the 1996 Peace Accords. There is no real consequence for the midwife who
does not attend trainings, beyond being unable to be the official midwife on the birth certificate
of the newborn. However, the Ministry of Health seeks to register all midwives and encourage
them to attend trainings, for the benefits reaped when midwives receive formal trainings from
health professionals. Additionally, there is further control and understanding of the pregnant
women, causes for maternal mortalities, and general health monitoring when there is open
communication between the midwives and the Ministry of Health.
Ministry of Health research participants believed that the benefits of trainings are
twofold, positively affecting the work of both the midwives and the health professional. Health
personnel claimed that over time trainings have resulted in evolving public opinions of the health
system, increasing referral to services for both prenatal control and deliveries, decreasing
maternal mortality, and strengthening midwife understanding of reproductive health.
Additionally, these health workers valued the power of interchanging experiences, indicating that
health professionals also learn from the midwives during trainings. They recognized that the
midwives do not have formal education, but argued that they are key figures in the community
health landscape. As one nurse noted, “they are the gynecologists of their communities”. As the
Ministry of Health lacks sufficient human resources to reach all rural communities, midwives
serve as the primary contact between the formal system and the community members. In this
way, participants concluded that training midwives is vital to the public health of the population.
Topics for trainings are largely based on a national program mandated by the Ministry of
Health, however many commented on their prerogative to elect topics that are relevant and
necessary in their specific context. Trainers remarked their use of adult education methods,
demonstrations, role-play, and experience interchange in order to facilitate trainings where this
population can thrive and “so they don’t sleep”. Concerning the effectiveness of the trainings
themselves, participants acknowledged room for improvement. Many stated that the presenter is
frequently underprepared, lacks adequate materials, or spends insufficient time teaching the
topic. Others remarked on the long distance midwives must travel to arrive at the training site,

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making them more likely to be tired, hungry, and therefore incapable of participating actively in
the training. Many believed that incentivizing or motivating the midwives would improve to the
current system. Further topics that health professionals would like to teach included infectious
diseases, family planning rights, code red emergency response, reading and writing classes, and
self esteem. When asked why self esteem as a topic, one participant made an eloquent point,
“…so they know that saving lives is difficult, that what they do is hard, but they are saving lives
and that’s very great.”
All participants answered the questions, “What would happen if midwives no longer
attended births? Would the Ministry of Health have the capacity to attend 100 percent of births in
Joyabaj?” Unanimously health personnel gasped, scoffed, laughed and even cursed at the
thought. The clear answer is that the Ministry of Health does not have near the capacity to attend
100 percent of births, in terms of both human resources and physical space. Many further
commented that referrals, prenatal controls, vaccinations, and growth monitoring would also
decrease in the absence of midwives promoting health services. To participants, the key is health
education:
People sometimes do things out of ignorance, no one has ever told them, they have never
learned…if they realized the dangers they risk in delivering at home this would make
them feel obligated, or have a fear that makes them come to hospital… But, this would
mean the hospital would need to be ready to provide quality attention for them.
Beyond continued midwife education, health workers claimed training community leaders,
health commissions, adolescents, and pregnant women would help reduce maternal mortalities.
They acknowledged the crucial role the midwife plays in the process, and hoped for improved
materials and resources to better train and equip the midwives of the municipality.
Organizations working with midwives. Three organizations participated in the current
research (five total participants) including “Pies de Occidente”, “Fundación para la
Alimentación y la Nutrición de Centroamérica y Panamá”(FANCAP), and “Médicos Descalzos”.
Pies de Occidente (Western Feet) researches reproductive health and trains both midwives and
medical professionals in the western highlands of Guatemala. FANCAP (also known as the
Global Network for Maternal and Child Health Research) studies reproductive health issues, the
role of traditional midwives, and provides resources for midwives. Médicos Descalzos (Barefoot

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Doctors) works in a neighboring municipality of Joyabaj training midwives and traditional
healers and studies topics relevant to community health and traditional medicine.
The organizations commented on the current role of the midwife and how her role and
competencies have been affected by the interventions of the Ministry of Health. Participants
argued that the role of the midwife today continues to be integral in providing services to the
rural populations, as “a mix between health provider, grandmother, companion, spiritual advisor,
and leader in the community”. The midwife garners respect, serves out of vocational calling, and
is sought by the community for health issues beyond the scope of maternal and child health. As
described by the participants, the midwife is the first response in the community, and is crucial in
the decision-making processes encountered during medical emergencies. These organizations
generally believe that the efforts of the Ministry of Health to train, register, and certify midwives
has been a positive effort to improve the knowledge base of traditional midwives and increase
interactions between the traditional and institutional health systems. One organization
commented that “we can no longer say they are 100 percent traditional midwives” now that
midwives have more equipment, training, and modern techniques. Another commented that the
true work of the midwife should never be changed, lamenting the effort of the Ministry of Health
to reach 100 percent institutional births. This would be “fundamentally against the culture and
traditional system of medicine.”
Participants from the organizations also contributed opinions on the worth of the current
official midwife training system, making recommendations from field and research experience.
Two main points were made across interviews: the focus on experiential interchange and the
proper preparation of materials and personnel for the trainings. Primarily, they stressed the need
to listen and respect midwives in order to successfully facilitate an exchange of ideas and
experiences amongst midwives, instead of making assumptions and blaming or scolding the
mistakes of individuals in front of the group. Minimizing blame and emphasizing collective
learning is critical to not only a more effective training, but also an improved relationship
between groups. Furthermore, participants commented on the lack of preparation on the part of
Ministry of Health personnel, in their ability to present material that is comprehendible for this
group and their capacity to adequately answer questions on the presented topics. In their opinion,
trainings should be participative, dynamic, and preferably with one consistent trainer with whom
the group is comfortable, thus instilling trust for the groups to share openly.

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Final comments offered by the participants pertained to further recommendations to
improve the relationship between the traditional and institutional health systems. One
particularly poignant quote encapsulates ideas on how to improve the relationship:
Yes, it is true that the midwives do not have formal education but this does not mean we
can ignore the years of experience they have working in women’s health. Yes, they can
do the job without many resources. There are of course some things they cannot do when
it comes to high risk and emergencies, but they can often do the job as well as a doctor.
Yes, they need support but adequate support that is appropriate to the culture, a
partnership that is not affecting their role as midwife, something that respects them.... this
is how we can find a compromise between the two systems.
As presented in this quotation, the interviewed organizations are advocates for the role of the
midwife in current day, and believe strongly that they deserve respect and recognition. Without
midwives, all agreed that the Ministry of Health would lack the capacity to handle the influx of
patients for prenatal control nor deliveries, maternal mortalities would likely increase, and many
women would be left without any form of health care. Trust and use of formal health services
would worsen, as midwives often act as advocates for prenatal controls, vaccines, and
institutional deliveries during emergencies. Furthermore, the traditional system offers culturally
appropriate services that the institutional system never would, such as house visits, a more
comfortable setting for patients.
Discussion
It is evident that midwives are highly experienced in their principal functions, and as a
consequence of years of formal trainings, continue to refine their skills and understand the limits
of their capabilities, relying on the Ministry of Health for high-risk patients and emergencies.
Midwives also succeed in promoting services offered by the hospital and health posts, increasing
the number of women who seek prenatal control, vaccines, and other services provided by the
formal health system. This is the quintessential example of the midwife’s potential to use her
influence to be an agent of change to break cultural beliefs and practices that work against the
population’s health. Furthermore, participants unanimously declare that the health system would
flounder in the absence of midwives, as the hospital lacks physical and human capacity to
monitor and attend the reproductive health needs of the entire population. Additionally, many
individuals would likely refrain from institutional care for cultural and logistical reasons, leaving

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them completely isolated from any health service provision. In this way, the population would
likely suffer from higher rates of maternal and child mortalities. These points all lead to the same
conclusion: the need for the two systems to work complementarily for both cultural pertinence
and ultimate resource utilization.
Across interviews, some points of inconsistency are apparent. Primarily, the question of
exactly which patients require an institutional birth continues to be an area of contention.
Culturally, a home birth is ideal, and therefore families fight to deliver at home with the extended
family present. The midwife supports this decision, with her experiential and economic
incentives to attend the birth in the home (many comments reveal that midwives commonly fail
to receive stipends from the families if the births are attended in the hospital). However, Ministry
of Health workers, despite recent increases in institutional births, insist and encourage even more
patients to deliver in the hospital. Specifically, there are developing mandates for all first time
mothers and women under the age of 19 and over the age of 35 deliver in the hospital because of
the high-risk of complication in these age groups. This mandate is contradictory to the widely
held belief that the hospital does not have the capacity to attend large influxes of patients. To
accomplish the goals of increased institutional births in the aforementioned high-risk groups, the
hospital would need a greater budget to hire additional personnel and construct physical space.
One compromise offered by the hospital director is the current plan to have a space in the
hospital for midwives to arrive with their patients to attend births in the hospital, and in the case
of an emergency, medical professionals could intervene. Nevertheless, this option still conflicts
with the prevalent desire to deliver in the home. In order to overcome these persistent cultural
barriers, the hospital needs to be transparent and work closely with midwives. In the case in
which midwives do not work harmoniously with the hospital, one can expect significant
ramifications for the population’s perceptions, trust, and utilization of institutional health
services.
Finally, to prevent further maternal mortalities, midwives, health personnel, and
institutions agree that the midwife is an essential player. To achieve this goal the key is
education, of both continued trainings for midwives, but also other populations. For example,
community leaders, community health commissions, and husbands are groups that need to be
reached in education activities and awareness campaigns. These groups all involve men, the true
decision makers in the machismo culture. Men are the decision makers in the community, and

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therefore need to be educated on the risks their wives, daughters, and sisters take when they are
refused from seeking formal medical attention.
Conclusions and Recommendations
Due to the cultural and financial context of the Joyabaj, midwives will continue to play a
leading role in the health of the population for the foreseeable future, therefore it is imperative
that the relationship between institutional health services and the traditional midwives is
harmonious and mutually constructive. In consideration of the observations, opinions, and
statistics offered in the current research, this paper argues for certain actions. Principally, it is
imperative that all Ministry of Health personnel both understand and respect the traditional
midwife. While study participants respect the midwives’ work, there are many medical
professionals who have limited contact with midwives and tend to be detached from the local
cultural beliefs and norms. Many midwives comment that they feel comfortable with the nurse
who trains them, but often find the doctors mean and disrespectful. One proposal is thus to train
all health personnel on the role of the midwife and introduce them to the midwives during
trainings, so that through introductions and increasing familiarity the doctors and midwives can
foster mutual trust. Through greater comprehension of the fundamental role of the midwife on
the part of health personnel, the gap between the two systems will begin to narrow.
In regards to trainings, session preparation must be thorough. In order to communicate
key health messages effectively to the midwives, materials and education delivery must take into
consideration adult education principals; utilizing demonstrations, practice, and visuals in a
language that matches the education level of the participants. While the district is given a
protocol for training topics, training facilitators need to tailor topics to the context, analyzing the
needs of the group. One possibility is to elect a small council of midwives to aid in the selection,
preparation, and facilitation of topics, ensuring the voice of midwives will be heard. Midwives
need to be empowered in trainings, not only in the technical aspects of their work as midwives,
but also in ancillary yet equally important topics such as conflict resolution, leadership, teaching,
and self-esteem. These topics are pertinent to the role of the midwife, who often finds herself in
combative environments where the female patient is unable to fight for her own health due to the
machismo culture prevalent in Guatemala. Additionally, trainings should be brought closer to the
homes of midwives, and delivered in smaller groups, in order to facilitate active participation and
decrease the inconvenience and cost of traveling to the urban center once a month for trainings.

19. Brunner 19
Finally, these same trainings should be offered to populations other than just midwives. Men,
adolescents, pregnant women, and community leaders alike should understand the emergency
signs in pregnancy and be part of the emergency action plans. When the entire population is
aware of maternal and child health issues, maternal mortalities should decrease.
In conclusion, the midwife is a figure who needs to continue to use her experience,
training, and community leadership as a crux in the effort to break negative perceptions of the
formal health system; bringing patients to the hospital as advised by medical professionals.
Cultural beliefs and norms must be reinforced with the realities and evidence of modern
medicine. Women who are determined medically capable should continue to deliver in the house
with her trusted midwife, with the intention and preparations to travel to the hospital in an
emergency. In some cases, this is achievable, however for families in the communities more than
an hour from the hospital, the safer choice would be to always deliver in the hospital.
Furthermore, rather than viewing the systems as “traditional” and “institutional” midwives and
medical professionals need to see themselves as a cohesive unit with the same overarching
mission to improve the health of the population of Joyabaj. These actions would support
improved health outcomes and quality of life of not only women in Joyabaj, but also the
population at large, in Joyabaj and other similar municipalities of Guatemala.

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Works Cited
Alvarado, Cristina Chávez, Pantó, Elvira Morales, y Felipe Pol Morales (2012). Conocimiento
tradicional de las comadronas sobre salud reproductiva. Asociación Médicos Descalzos:
Chinique, El Quiché, Guatemala.
Center for Economic and Social Rights (2008). Guatemala Fact Sheet No. 3. Retrieved from:
http://www2.ohchr.org/english/bodies/cedaw/docs/ngos/CESR_Guatemala43_en.pdf
Gallegos, Rafael, Aguilar, Carol (2003). Conocimientos, actitudes, prácticas, preferencias y
obstáculos (CAPPO) de las madres sobre la salud infantil y materna desde el contexto
cultural Maya y Occidental. Asociación Pies de Occidente: Guatemala.
Gallegos, Rafael Vasquez (2011). Consideraciones históricas, políticas y legales de la medicinia
indígena en Guatemala. Asociación Pies de Occidente: Guatemala.
Ministerio de Salud Pública y Asistencia Social (2010). Manual de capacitación a facilitadores
para la capacitación de comisiones de salud. Republica de Guatemala.
Ministerio de Salud Pública y Asistencia Social (2010, 2011, 2012, 2013, 2014). Indicadores
Básicos de Análisis de Situación de Salud. Departamento de Vigilancia Epidemiológica:
MSPAS, República de Guatemala.
Ministerio de Salud Pública y Asistencia Social (2014). Banco de información de comadronas
tradicionales por comunidad y jurisdicción. Distrito de Joyabaj, El Quiché.
Ministerio de Salud Pública y Asistencia Social (2015). Reseña Histórica. Retrieved from:
http://www.mspas.gob.gt/index.php/en/resena-historica.html
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http://data.worldbank.org/country/guatemala#cp_wdi
World Health Organization (2013). Global Health Observatory: Maternal and reproductive
health data. Retrieved from http://www.who.int/gho/maternal_health/en/
MSPAS and SEGEPLAN (2010). Estudio nacional de mortalidad materna 2007. Informe
preliminar. Guatemala, Ministerio de Salud Pública y Asistencia Social; Secretaría de
Planificación y Programación de la Presidencia: Guatemala City.
SEGEPLAN/DPT (2010). Plan de Desarrollo Joyabaj, Quiché. Consejo Municipal de
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Presidencia, Dirección de Planificación Territorial, Guatemala.

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Socop, Carlos Enrique Lix (2007). Diagnóstico sobre la situación de políticas y programas del
Ministerio de Salud en la prestación de servicios de salud con pertinencia cultural en el
primer nivel de atención. Asociación Pies de Occidente: Guatemala.

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Appendix
INTERVIEW QUESTIONS
Study Group 1: Midwives in the Municipality of Joyabaj, Quiché, Guatemala
1. How old are you?
2. How old were you when you began working as a midwife?
3. Where and how did you learn to be a midwife?
4. How many children have you delivered?
5. How many deliveries did you attend last year?
6. How many deliveries have you attended this year?
7. How many patients are you currently attending?
8. How often do you meet with your patients during pregnancy and after birth?
9. What kind of information about pregnancy do you share with your patients?
10. Where do you normally attend births?
11. How much time do you spend with your patients after delivery?
12. Have you ever traveled with your patient to the hospital/health post to attend the birth?
How was the experience?
13. Do you receive any form of payment in your work as a midwife?
14. What is the most difficult component in your profession as midwife?
15. When did you begin attending monthly trainings with the Ministry of Health?
16. Have you seen a change in your work as a midwife since you began attending trainings
with the Ministry of Health?
17. Do you think the trainings have helped you become better at your job as a midwife?
How?
18. What do you think of the trainings given in the hospital or health centers?
19. What more would you like to learn during Ministry of Health trainings?
20. Are there further resources that would help you in your work as a midwife? Which?
21. What more can we do to prevent maternal mortalities?
22. How can we improve the relationship between midwives and Ministry of Health
workers?
Study Group 2: Ministry of Health Workers
1. What is your job title in the Ministry of Health?
2. How many years have you been working in the Ministry of Health?
3. When did the health district begin training midwives?
4. How long have you been training and working with midwives?
5. Have you seen changes in health outcomes of the population since beginning midwife
trainings?
6. What is the biggest challenge in your work as a midwife?
7. How do you choose the topics for monthly trainings?
8. Are there other topics you think need to be taught in trainings?
9. What teaching methods do you use in midwife trainings?
10. How do you think midwives benefit from monthly trainings?
11. Why do you think it is important to train midwives?
12. How do you think we can we improve the monthly midwife trainings?

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13. What would happen if midwives no longer attended births? Would the Ministry of Health
have the capacity to attend 100 percent of births in Joyabaj? Please explain.
Study Group 3: Institutions working with midwives
1. Please describe your organization, its history and its functions.
2. What is your job title in this organization, and for how long have you been working in
this position?
3. What is your experience working/studying the role of traditional midwives?
4. In your opinion, how has the role of the traditional midwife in the communities changed
as a function of the development of the Ministry of Health?
5. In your opinion, please describe the current role and importance of traditional midwives.
6. What is your opinion of the midwife training system implemented by the Ministry of
Health?
7. How do you think the training system can be improved?
8. How can we improve the relationship between the formal and informal health systems in
Guatemala?
9. What would happen if midwives no longer attended births? Would the Ministry of Health
have the capacity to attend 100 percent of births in rural areas of Guatemala? Please
explain.
10. Do you have other comments about the Ministry of Health, midwives, or other ways to
reduce maternal and child mortalities in Guatemala?