The comadrona and response to obstetrical emergencies : maternal mortality in highland Guatemala

The comadrona, the traditional birth assistant (TBA), in Guatemala still delivers almost 80% of Guatemalan babies in rural areas with large indigenous populations. She is a community leader and is well-respected for her work. However, Guatemala has a very high maternal mortality rate. In some departments as many as 230/100K women die per year. The comadrona is often blamed for these deaths. In many Central American countries the TBA has been outlawed or forced out of her practice. By analyzing the reasons that women die in childbirth in rural Guatemala I show it is not necessarily the comadrona's fault, but rather the lack of a community's ability to respond in time to an obstetrical emergency. Based on 20 qualitative interviews with comadronas, medical personnel, community leaders, and medical administrators, I analyze the meaning of maternal mortality in rural Guatemala. I review the location of the comadrona in these narratives and the connection between competing health systems and maternal mortality statistics. I show one of the major causes of maternal death in rural Guatemala, postpartum hemorrhage, cannot be predicted and can be fatal in less than 2 hours. The comadrona and the small regional health posts that serve rural populations are not equipped to respond to obstetrical emergencies or to stabilize and transport the mother. Together these findings point to the need to plan for and resource community response to obstetrical emergencies, and the need for better communication between the client, her comadrona, and emergency responder