Improving Maternity Care Where Home Births Are Still the Norm: Establishing Local Birthing Centers in Guatemala That Incorporate Traditional Midwives

"To accelerate the decline of maternal mortality and facilitate the provision of essential newborn care in rural areas, the development of locally available birthing centers similar to the casas developed in rural Guatemala and the integration of the functions of traditional midwives into the services provided at these centers can not only be a useful strategy but also serve as a new paradigm for the creation of more effective and just local health systems that engage communities as active partners."

In 2010, the World Health Organization published guidelines for collaborating with communities and families to improve maternal and child health. These guidelines strongly recommend partnering with traditional midwives because of their close ties to communities, cultural knowledge, and social acceptability and standing. More than half of births among Indigenous women in Guatemala are still being attended at home by traditional midwives with no formal training. Besides attending to women during pregnancy and delivery, these comadronas are trusted confidantes to women in a male-dominated culture, providing physical, emotional, and spiritual support. This article describes the incorporation of comadronas into casas maternas (birthing centres) in the Cuchumatanes mountains in one of the most isolated parts of the Department of Huehuetenango, Guatemala.

As part of the Maternal and Child Health Project (2011-2015), funded by the United States Agency for International Development (USAID)'s Child Survival and Health Grants Program, Curamericas/Guatemala worked with its US-based supporting partner Curamericas Global to develop and implement an approach called the Expanded Census-Based, Impact-Oriented Approach (CBIO+) to address inequities in maternal and child health. Casas maternas were established as part of this approach.

In brief, the casas are strategically located within a half-hour drive from the communities they serve. They are constructed and managed with volunteer labour by the surrounding communities (called partner communities). The casas are staffed 24 hours a day, 7 days a week by local Maya-speaking personnel who are trained in safe birthing practices and closely supervised and continually trained. The casas intentionally have an ambience more like an Indigenous home than a clinic, including a traditional kitchen where families can prepare traditional meals and an adjacent sweat lodge (chuj). 

For this study, interviews were conducted over a 10-year span (2013-2023) to understand how comadronas, casa staff, and casa clients view casas and the integration of comadronas into the casa model. These data complement the quantitative data collected routinely on casa utilisation and maternal outcomes in 3 municipalities of Huehuetenango.

From 2011-2015, there were an estimated 94 comadronas serving the 3 municipalities (approximately 1 comadrona per 1,000 people). Through the end of 2023, these casas maternas had cared for 4,322 women giving birth. No maternal deaths occurred at a casa, but 4 died after referral. Data indicate that delivery at a casa materna is associated with an 8-fold reduction in maternal mortality relative to home delivery.

From the outset, the project considered comadronas to be an integral part of the casa team. Once the mother goes into labour, the comadrona accompanies her to the casa and joins the team there. Through this model, comadronas continue performing many of their traditional practices for their client before, during, and after the birth but in close collaboration with the formally trained health care staff at the casas.

The research found that, although there was initial resistance to the casa, comadronas and clients have become increasingly enthusiastic about them. The casas provide the opportunity for comadronas to continue the cultural traditions of prayers, massages, and other practices that honour the vital spiritual dimension of childbirth close to home in a home-like environment with extended family support while at the same time providing a safer childbirth experience in which complications can be detected by trained personnel at the casa, managed locally, or promptly referred to a higher-level facility. Clients interviewed in 2023 mentioned that their comadrona provided them with confidence, emotional support, and encouragement through their presence because they knew the mother well, had often attended their previous birth, and had knowledge inherited through many generations. Clients said that they trusted their comadrona.

From the perspective of casa staff, comadronas created a critical link between casas and communities. Because comadronas hold important influence in communities, they served the casa team by providing maternal education, which may not have been as well received from casa staff alone, and by encouraging women to give birth in a casa. Some comadronas even stated they told clients they would work with them only if they agreed to give birth at a casa. That said, comadronas said they spent a lot of time trying to convince families to allow the mother to give birth at a casa but sometimes encountered resistance because of the families' traditional beliefs about the necessity of a home birth. 

Putting the findings into a broader context, the researchers note that "the Indigenous population of Guatemala has suffered centuries of discrimination, marginalization, exploitation, and, at times, outright genocide. The formal health system also reflects this marginalization and contributes significantly to the poor health outcomes experienced by Indigenous Guatemalan women and children. The casa approach, with its foundation in the empowerment of and partnership with Indigenous communities, including their comadronas, represents an important step away from this tragic marginalization."

According to the researchers, the Ministry of Health of Guatemala has adopted this approach and has begun to implement it in other rural areas where home births still predominate. 

In conclusion, "incorporating traditional midwives into local, readily accessible, community-based, and community-supported birthing centers that have more highly trained (but still low-level) staff, follow protocols for safe delivery, and have a system for prompt transport of women with complications represents a useful 'middle way' in other geographical areas around the world where home births are still the norm and higher-level health facilities are not close nor readily accessible (and may never be due to profound economic, political, and geographic constraints). The casa materna approach represents a potentially feasible and effective strategy for reducing the unnecessarily high levels of maternal, perinatal, and neonatal mortality while at the same time providing respectful care that honors these cultural traditions and integrates communities and their rich social capital."