This February, our Safe Motherhood team was comprised of a Canadian doctor and maternity nurse and 3 Guatemalan Registered Midwives. We went to el Novillero, Sta. Lucia Utatlán, Guatemala. This little town is perched in the highlands along the Pan American Highway. At an altitude of 2800M (9100ft), the days were warm up to 25C but the nights were very cold at this time of year down to 0C with frost.
Our first week, we taught 30 comadronas (traditional midwives). The course started with registration of all the students, words of welcome by the mayor and the commander of the municipal fire and ambulance department and a representative from the municipal office of women’s affairs. We then had our “talking circle,” based on North American indigenous talking circles, with everyone introducing their self and sharing their previous experience and their hopes for the course.
We then got down to work, basing our course, as usual, on the 3 primary causes of maternal death: hemorrhage, infection, and eclampsia (a serious illness in pregnancy causing high blood pressure and seizures). Our first practical lesson was the care of hands and fingernails with the comadronas watching a demonstration of hand washing using a surgical scrub and then everyone doing a return demonstration. This was a new technique for all and was practised every day before the beginning of each class.
After discussing the probable signs of pregnancy and how to confirm the pregnancy, by hearing the fetal heartbeat, they learned how calculate an estimated due date and practised from many examples given to them. Normal progression of pregnancy was shared as well as warning signs of possible complications along with appropriate actions and advice. After a demonstration of a prenatal interview, all present were divided into pairs and practised their own interviews to demonstrate their understanding of our teaching so far.
The next day, after handwashing, we had a brief review of the previous day and discussed any doubts concerning what they learned. We then demonstrated a complete physical exam of a pregnant woman including the process of determining the position of the baby in the uterus. They all practised the manoeuvres with our models and were joyfully surprised that with practise, they could feel the position of the fetus. They learned the importance of this skill in prevention of complications especially when living in small communities with difficult access to a hospital.
After a demonstration of an assessment of a woman in early labour, leading on to a demonstration of a normal birth, everyone was divided into groups of 5-6, to do their own demonstrations of normal births. This helped to reinforce what they had just learned as well as to show us that they understood the many important concepts that we taught. Everyone enjoyed being part of the role-playing and helping each other “birth” their babies!
We finished the day with an important discussion of nutrition during pregnancy and while breastfeeding. All present shared an example of food brought from home, having been asked the day before, and shared what it contained that made it important in pregnancy.
After a (daily) nutritious lunch, everyone returned home. Another very full day!
We had the privilege of having a couple (both traditional healers) from a small community in Huehuetenango (an 8-9 hour bus ride away) present at our course. They had heard about our course and wanted to take it so they could return to their community and share their experience with the elders and comadronas of their area with hopes for us to bring the course there. They were very pleased to be part of the course and saw first hand why our hands-on model of teaching is so important. They would be important facilitators as well, as they speak Mam, Spanish and English and really understand the subject matter of the course.
Our final day of class began with a review of all the information taught so far. We also covered topics such as:
1. Breastfeeding and avoiding sore nipples
2. Family planning and the spacing of pregnancies
3. Emergency planning for families- preparedness in case a complication arises during labor requiring the transport of the woman to hospital.
4. We discussed the identification of high-risk pregnant women so these women could be counselled to birth their baby in hospital.
5. Management of complications during labor and delivery:
a. hemorrhage- recognizing too much bleeding and practice of uterine massage
b. umbilical cord around baby’s neck
c. babies with “stuck shoulders”-
Gestational Diabetes is common here in
d. unexpected breech baby
d. convulsions of eclampsia
e. neonatal resuscitation with ventilation by mouth to baby’s nose and mouth.
We closed the course with our talking circle once more. The students proclaimed this to be the most practical and useful course they’d ever taken. While many of the comadronas had received some training previously, they declared that they had never had any hands-on demonstrations or practice prior to this.
We had the opportunity to visit a contact in a community in the department of Qu’iché. Joyabaj is quite a large city, a regional center surrounded by pine forests, cornfields and many small villages. We met with the mayor, the municipal director of women’s affairs, and the director of the regional public hospital. All were very receptive to the description of our course and asked for us to bring our course there, especially for the rural comadronas of the region. With some planning we may be able to teach there in February 2020. There are 324 comadronas registered in this area. Several trips will be required to provide the course to as many of these comadronas as possible. Maximum class size is 30 students.
From Joyabaj, we travelled over ridges and into ravines on rough roads to the very tiny village of Piedras Blancas to visit a rural primary school of over 100 students to distribute kits of re-usable menstrual pads to the Grade 6 girls. We had been asked to bring a case of kits to distribute while in Guatemala. “Days for Girls” is a project that makes and supplies the kits to adolescent girls so they need not miss school because of their period. Many families do not have adequate funds and do not spend scarce money on disposable sanitary pads. We spoke to a class of 17 Grade 5-6 girls aged 12-14. Cenaida spoke of the normal process of maturation and menstruation. We demonstrated how to use the re-usable pads. The girls seemed eager to receive us. We gave a kit to each girl present. 3 girls refused for reasons unknown.
We taught 22 bomberos (volunteer firemen/ paramedics) and 8 nurses (4 public health nurses and 4 recently graduated nurses) our second week. We compressed our course into 2 days, as many participants were unable to get 5 days off. They were an eager bunch!!!! Our days were 8.5 hours long, with a short lunch break.
As usual, we started with our registration and our “talking circle” and then got down to covering the many topics necessary to ensure understanding of a normal birth experience before covering all the information required to ascertain when the risk factors indicated the need for a higher level of care. It was a super busy day filled with lots of “aha” moments, surprises and laughter in the midst of all the new knowledge and skills. As all the participants in this group were literate, we were able to progress through some of the topics very quickly. This gave us more time to focus on the topics that required more in-depth discussion and instruction and gave time to practise until everyone was comfortable with each skill set.
Our second day was filled with learning the skills required when called on when a complication arose during a home birth. The bomberos and nurses were totally captivated in learning a large variety of hands-on emergency skills. They not only practised the skills on our models, but immersed themselves in role-playing complicated births using their new skills to respond to emergencies in a timely and professional manner. They learned what to do if the birth occurred while en-route to hospital and how to prevent further complications from arising. They learned not only the team work required between themselves as bomberos and nurses, but also how to support and communicate with the comadrona in her role as the support person for the labouring mother. It was a good lesson for all involved to learn what their individual roles were in emergency situations until arrival at the hospital where they would communicate clearly what had transpired.
Once again in our closing circle, we heard expressions of gratitude for bringing our interactive and hands-on course to their community. They said that they had never received such a useful, practical course in their training as volunteer paramedics or as nurses, although, it was evident that many had received a lot of useful theory throughout the years.
Because we completed the course in 2 days, it gave us a day to return to San Juan Argueta where we had taught 3 years ago. We were able to spend time in the local market and then reconnect with a couple of the bomberos we had trained previously. We heard stories of the important role that our course played in helping the comadronas and bomberos in their current work. They remain very thankful and continue to practise and use their skills. It was lovely to meet and have lunch with one of the bomberos and his family in their home and learn more about their lives.
Thursday was graduation day for all of the students from both weeks. After the singing of the Guatemalan national anthem, and the regional bombero association anthem, there were a few official speeches by the Mayor, and team members of our project. This was followed by all the graduates being called up individually and receiving congratulations from the mayor and the team mates, along with their diploma, a photo of the group they were part of, a kit of supplies for the up coming births they attend, and a packet of baby clothes wrapped in a receiving blanket for the next birth they attended.
The comadronas and nurses presented traditional dances and had the team members participate with them. The bomberos and nurses then presented a play of a birth to everyone to demonstrate their newly learned skills and knowledge. The joy of learning was evident on the faces of all the students.
Afterwards, a painting by a local artist and a tablecloth woven in the traditional style of Santa Lucia were presented the Safe Motherhood team by the students. Juan, one of the bomberos, then presented each member of the team with a rose from his garden as a symbol of gratitude to Rose Charities Canada for the Safe Motherhood Project giving their course for the people of el Novillero.
The graduation ceremony was very moving for all the participants, many photos were taken, hugs given and received along with tears of farewell. Promises were made to have monthly get-togethers to practise and review the skills.
Providing we have adequate funding, our Guatemalan teammates are prepared to go to other towns that have requested our course in the coming year. Please consider donating to this cause.