Reducing maternal mortality rates worldwide has been a major global health priority since the World Health Organization’s Safe Motherhood Initiative in 1987. In many low- and middle-income countries (LMIC), lay midwives, rather than biomedical personnel, attend the majority of births. As such, for several decades, training programs for lay midwives have represented a major strategy to reduce maternal mortality in the world’s poorest countries. These programs are often sponsored by governments, international aid agencies, and non-governmental organizations, which offer midwives short curricula about pregnancy and birth-related topics from a biomedical perspective. In some cases, midwives must complete these courses in order to obtain a license to practice legally.
In recent years, global health policy has shifted away from midwife training, particularly in light of the UN Millennium Development Goals, which emphasize improving women’s access to “skilled birth attendants” (SBAs)—namely, physicians and nurse midwives. However, SBA provider shortages and inaccessibility are still important issues in many LMIC, and midwives, who often provide culturally meaningful and linguistically appropriate care for patients, remain the first resort for many pregnant women. As such, midwife training programs still operate in many countries and can play a role in improving birth outcomes.
There are, of course, many problems with midwife training programs around the world. A very common critique is that these programs are not always “culturally appropriate.” For example, course instructors might employ a didactic format in contrast to midwives’ experiential and interactive modes of learning. Trainers may rely heavily on written materials among midwives with limited or no literacy. And often, training programs are offered in colonial languages, rather than locally-spoken languages, constraining participants’ abilities to fully engage with information presented.
Recently, I came across a study from Guatemala that powerfully reiterates these messages about the role of culture and language in midwife training programs. In 2013, Médicos Descalzos Chinique (Barefoot Physicians of Chinique), a non-governmental association dedicated to preserving and promoting Maya therapeutic knowledge in Guatemala, published a book (Midwives’ Traditional Knowledge about Reproductive Health) about the practices and experiences of 75 indigenous K’iche’ Maya midwives. Lay midwives represent extremely important community resources in Guatemala, where up to 70% of births outside of urban areas occur in the home. As well, midwives are especially valuable providers for the nation’s majority indigenous population, which faces many structural, linguistic, and cultural barriers to accessing prenatal and obstetric services.
Midwives’ Traditional Knowledge about Reproductive Health describes the social roles of indigenous midwives in Guatemala, contains an index of frequently-used herbal remedies, and documents ethnomedical knowledge about reproductive anatomy, pregnancy, childbirth, and the puerperal period. Additionally, as all of the interviewed midwives had participated in midwife training programs, one section focuses exclusively on their insights about training curricula. Midwives’ direct recommendations for anyone wishing to collaborate with them in training efforts were (my translation from Spanish of pp. 34-35):
“That the themes of the discussions and the trainings be given in the K’iche’ language, as many of the midwives have only basic comprehension of Spanish, and further, it is difficult for them to express themselves or ask questions.”
The majority of midwife training programs in Guatemala occur in Spanish, the colonial language, despite the fact that many midwives speak one of the country’s twenty-three indigenous languages monolingually. As reported by the NGOs Refuge International and Maya Health Alliance, offering courses in midwives’ primary language can have a positive effect on class participation, retention of new information, and skill development.
A Kaqchikel midwife at the opening of a midwives’ cooperative clinic, ACOTCHI (acotchi.org), in Guatemala. Photo by Anita Chary.
“That they [the midwives] be consulted about the themes of the training: often, Ministry of Health service staff assign very basic themes to the midwives, such as hygiene and general care. If one wishes to truly support the midwives, it is necessary to consult with them about the lessons they would like to learn, and about what they feel is necessary to learn.”
At some Ministry of Health-sponsored midwife training sessions that colleagues from Maya Health Alliance and I have attended, we have been similarly surprised at how unsophisticated some of the lessons are. The basics of handwashing and the existence of sexually-transmitted diseases do not seem appropriate topics for practitioners who can explain subtle differences between placental abnormalities. Additionally, in our experience working with a midwife cooperative in the western highlands, midwives are often enthusiastic to learn about biomedical topics not restricted to childbirth—for example, child nutrition, diabetes, and common remedies for parasitic infections.
“That their experience [of the midwives] be taken into account. That is to say, when a lesson is given, the midwives should be consulted about what traditional practices they apply in that context, trying to understand their knowledge without the idea that all traditional techniques are mistaken superstitions or even dangerous.”
Midwives in Guatemala often report being scolded during midwife training programs for indigenous ethnomedical practices, such as massaging a pregnant woman, suggesting that she use the sweatbath (tuj/temazcal), or delivering a baby in a kneeling or squatting position. From a biomedical perspective, these practices are likely innocuous, and indeed, non-supine birthing positions may actually facilitate childbirth. However, locally, biomedical practitioners sometimes view midwives’ practices as “cultural beliefs” that ought to be eradicated, rather than as legitimate pieces of knowledge.
“That the midwives be respected and not scolded as if they were children: there may be differences or misunderstandings, but that is never a justification for attitudes that assault their dignity. It closes the door to any possibility for dialogue with them. At best, they will continue attending meetings because of obligation, but will no longer have any trust or expectation for dialogue in the health services.”
Discriminatory and disrespectful behaviors towards midwives take a variety of forms. In Guatemala, midwife training program instructors are often non-indigenous biomedical providers who may be significantly younger than course participants. Instructors may address midwives informally as “tú” or “vos” (you) or “niña” (girl), rather than formally as “usted” (you) or “Doña” (a respectful form for an older woman). On some occasions, colleagues from Maya Health Alliance and I have seen instructors yell at or berate midwives for being “dirty” (from working in agricultural labor), arriving to class late, or whispering with neighbors—even if doing so is an attempt to translate what is being covered from Spanish into a locally-spoken indigenous language. Midwives interpret such overt mistreatment as a form of ethnic discrimination; as one Kaqchikel midwife remarked, “They see that you are Kaqchikel, indigenous, and they treat you as if you were inferior.”
These are important lessons for anyone involved with midwife training in LMIC—specifically, staff of Ministries of Health, NGOs, and volunteer medical missions. Collaborating with midwives to develop courses that include topics they identify as important, offering instruction in locally-spoken languages, valuing their knowledge systems, and engaging with them respectfully are all significant actions we can take to improve training programs and, ultimately, contribute to worldwide efforts to reduce maternal and child mortality.
Asociación Médicos Descalzos
2013 Conocimiento Tradicional de las Comadronas sobre Salud Reproductiva. Chinique, El Quiché, Guatemala: Cholsamaj.
This was originally published on Global Health Hub: http://www.globalhealthhub.org/2014/05/27/improving-midwife-training-programs-indigenous-lay-midwives-recommendations-guatemala/