Comadronas: Guiding the Pregnancies of Healthy Mothers and Babies in Western Guatemala

June 06, 2022

Comadronas: Guiding the Pregnancies of Healthy Mothers and Babies in Western Guatemala

By Cristina Maldonado, Felipe López, and Gustavo Barrios

On November 8, 2021, a doctor at the health center in Guatemala’s Zunil municipality, Quetzaltenango department, called Romelia—an experienced comadrona (traditional midwife) and president of the municipality’s comadronas association—to inform her that a pregnant woman was presenting with bleeding and that both her life and that of her baby were in danger. The doctor had referred her to the local hospital, but the woman—Francisca, who was pregnant with her second child—preferred not to go. Instead, the doctor asked Romelia to accompany him on a home visit. Upon arriving at the house, Romelia gently explained to Francisca and her husband how risky the situation was for her and her baby, as well as the care she could receive at the hospital. Following these explanations, the couple decided to seek medical attention and asked Romelia to accompany them to the hospital. The child, a healthy baby boy, was delivered by Caesarean section due to placenta previa, with no further complications for the baby or the mother.

The Role of Comadronas in Promoting Maternal and Newborn Health in the Guatemalan Highlands

In the western highlands of Guatemala, traditional midwives or Iyom (grandmother midwives) are key actors during pregnancy and childbirth, long serving as the first points of reference in Indigenous women’s health seeking pathway in rural areas. They accompany women throughout the pregnancy to childbirth and postpartum care, both in the women’s homes and at public health facilities. They are a key link between the family and the health care system, guiding and counseling women on self-care during pregnancy, delivery, and the postpartum period. This includes providing guidance on the food, tea, and medicinal herbs they should consume to improve their heath and the health of their baby during pregnancy; identifying signs of complications; and incorporating symbolic cultural objects into their prenatal care routines—such as tying red ribbons around the abdominal area or fixing bags filled with quartz stones, obsidian, ocote, or lemon to their bodies—to protect them from diseases or negative energies.

During the COVID-19 pandemic, many women were afraid to seek services at health care facilities due to risks of exposure to the virus. Furthermore, some facilities were closed for months at a time, while containment measures such as curfews made accessing the facilities that remained open more difficult. Due to these and a wide range of other factors, the entire region saw a reduction in the percentage of births attended by the Ministry of Public Health and Social Assistance (MSPAS) and an increase in the care provided by traditional midwives during pregnancy and childbirth. On average, MSPAS attended nearly 55% of births in 2019, but that fell to below 48% in 2020.[1] In recognition of their critical role, the Ministry provided comadronas with a special exemption to the curfews and stay-at-home orders, allowing them to mobilize and attend to the needs of pregnant women at any time, day or night.

Romelia (left), a traditional midwife, played an important, lifesaving role for Francisca (right) by referring and accompanying her to the hospital during the birth of her second son.

Utz’ Na’n: Working Together to Build Capacity and Save Lives

The Utz’ Na’n Healthy Mothers and Babies project is implemented by Management Sciences for Health (MSH) in Guatemala’s Quetzaltenango and San Marcos departments in partnership with PIES de Occidente and the National Observatory of Reproductive Health. Its objective is to strengthen local capacity to provide high-quality and culturally sensitive antenatal care (ANC) to Indigenous women and adolescents. Through this approach, the project aims to improve early use of and adherence to ANC services, thereby preventing maternal mortality and improving women’s health and the health of their newborns. Traditional midwives are key players in the community and in this project given their critical role in engaging pregnant women early on, referring and accompanying them to the nearest health center, and helping them identify possible risks and danger signs throughout their pregnancies.

As part of this process, when the COVID-19 pandemic began in Guatemala, Utz’ Na’n and the Quetzaltenango Health Area joined together to deliver a series of virtual training courses to comadrona leaders on COVID-19 transmission and infection prevention and control and provided comadronas in 13 health districts with personal protective equipment and supplies. In addition, the project provided eight associations of comadronas with basic equipment for antenatal screening and care and trained the teams in their use. With this support, they were able to identify pregnant women with high blood sugar and high blood pressure, including among their own comadrona teams, and referred them to the health services for evaluation and care.

Francisca and her son.

Achieving Real Change for Mothers and Babies

The project has had a lifesaving impact on many mothers and babies, including Francisca and her son. “I am very grateful for Romelia,” she says, explaining that the comadrona also attended her sisters’ births. Francisca says that Romelia’s support during the birth of her son made her feel more confident to seek medical care at the local health facility in the future. “I had the confidence to go to the national hospital for care because I was at risk of dying from blood loss,” Francisca explains. Romelia continues to follow up with Francisca during occasional home visits, receiving appreciation from the whole family, but she is also very thankful. “I am grateful to Francisca because she followed my recommendations,” she says proudly, “and I was able to save her life and continue caring for her sons.”

Currently, Utz’ Na’n, in coordination with MSPAS, is carrying out activities to promote the integration of comadronas in 24 health districts and 100 communities in Quetzaltenango and San Marcos. Under the National Policy of Midwives of the Four Peoples of Guatemala (2015–2025), the role of traditional midwives and their relationship with the national health system are recognized and strengthened. This year, for the first time, May 19 was officially recognized by the Government of Guatemala as the National Day of the Traditional Comadrona. On this day, the Quetzaltenango and San Marcos health area teams and Utz’ Na’n co-hosted a celebration with comadrona associations to recognize their important contribution to improving women’s health in the region. MSH remains committed to improving access and the right to health for all women in Guatemala and achieving the goals of the project, hand in hand with comadronas, health care teams, and local communities.

About the Authors

Dr. Felipe López is the Utz’ Na’n Project Director and is a public health expert with 30 years of experience in the public health system in Guatemala, with deep expertise in maternal, newborn, and child health.

Dr. Gustavo Barrios, the project’s Senior Technical Advisor, is a public health specialist with more than 25 years of experience supporting the design and scale-up of culturally responsive and integrated care for pregnant women and children in community health programs, with a special focus on Indigenous communities.

Dr. Cristina Maldonado is the Monitoring and Learning Advisor for the Utz’ Na’n project and brings 20 years of experience in general medicine and public health, including extensive experience in community-based health projects and capacity building for health institutions.

[1] National Institute of Statistics. INE. Vital Statistics, 2020.