Professional Midwifery: Learning from the Past and Present to Inform the Future of Maternal Health Services in Guatemala

Guatemala has an unacceptably high maternal mortality ratio (MMR) of 140, andimprovements in this area have been slow. Furthermore, gross inequalities in healthoutcomes exist within its population, with over 70% of maternal deaths in Guatemalaoccurring among indigenous Mayan women. Mayan communities have been historicallymarginalized, and most Mayan women prefer the services of traditional birth attendants(TBA). As such, a disconnect exists between the formal and traditional health sectors inGuatemala, contributing to poor maternal health outcomes. It is widely agreed thatprofessional midwifery is an important component of safe motherhood strategies that canreduce maternal morbidity and mortality. Today the Guatemalan Ministry of Health isreintroducing midwifery for the first time since 1960. Given the potential professionalmidwifery has to address the obstetric care needs of Mayan women and bridge the gapbetween the health sectors in Guatemala, formative research is needed at the outset toinform the design and implementation of this program.This dissertation aims to inform future directions for professional midwifery in Guatemalaby assessing and analyzing historical policies and current perspectives and presentingcontext-specific recommendations for the future. The first paper looks to the past toconsider how international and society-centered forces influenced the creation of policies inGuatemala regarding birth attendance since the signing of the Peace Accords in 1996 up tothe reintroduction of midwifery. Next, the second paper elucidates the misperceptions,attitudes and expectations about the addition of midwifery to the healthcare system byGuatemalan physicians, nurses, midwives and TBAs today, identifying potential threats andfacilitators to this strategy’s success in Guatemala. Finally, the third paper proposesrecommendations for the future, considering identified impediments to midwifery’s capacityfor sustainability. This dissertation provides findings that can improve the design,implementation, monitoring and evaluation of the professional midwifery strategy inGuatemala, and can inform program and policy decisions to implement this strategy inGuatemala, Latin America and beyond