1. Comparing Childbirth Practices in Santiago Atitlán, Guatemala Connections, Variations, and Conflicts in Traditional and Biomedical Obstetric Care Melissa Gadilla Dr. Claudia Valeggia Health and Societies April 27, 2011

2. Two Birth Stories Magdalena’s and Chonita’s birth experiences Magdalena gives birth at home with Antonia, a 77 year-old traditional midwife (comadrona) Chonita gives birth at the free birth clinic in the Centro de Salud with a physician and two auxiliary nurses Narratives to represent present day obstetric practices in Santiago Atitlán

3. Background: Santiago Atitlán Located in the western highlands of Guatemala in the state of Sololá Population: 44, 220 inhabitants 98.18% Maya Tz’utujil 1.82% non- indigenous Site of major state-sponsored violence during the country’s 36- year Civil War Severely affected by Hurricane Stan in 2005 causing hundreds of deaths and homeless

4. Social Context Economy of agriculture, fishing, and tourism More than half of all families in Atitlán earn less than $200 a month The “Exclusion of the Maya” Disparities that inflict Atitecos today contingent to their history and strong sense of cultural retention

5. Maternal Mortality in Guatemala Guatemala has the highest rate of maternal mortality (MM) in Central America and third highest in Latin America ~ 290 deaths per 100,000 live births 80% of childbearing women are attended by a traditional birth attendant Department of Sololá has the 3 rd highest MM rate in Guatemala MM profile: “A woman of indigenous background, with little or no education, who intended to give birth at home with a comadrona.”

6. Medical Pluralism in a Tz’utujil Culture Coexistence of two medical systems: traditional medicine and a biomedicine

7. Traditional Medicine Historically, most widely-used system Composed of traditional healers (curanderos) and traditional midwives (comadronas) Hierarchy of resort today continues to be skewed towards traditional medicine Group of ~28 comadronas Informal women’s health system: assist women throughout all stages of pregnancy and treat issues related to gynecological care

8. Profile of the comadrona Unclassifiable and heterogeneous Generally an older woman, often with minimal or no schooling, who lives in the community and is recognized for her experience caring for pregnant women” Vary in process of selection, formation, and reproduction No formal training

9. Biomedical Community Lack of strong centralized health care system model trickles down to smaller villages like Santiago Biomedical community: Centro de Salud with integrated birth clinic Hospitalito Atitlán Rxiin Tnamet Prodesca Private doctors Not a consolidated community United by the “Red de Salud”

10. Research Questions What factors influence the childbirth practices of traditional midwives and physicians in present day Santiago Atitlán? Connections: Where comadrona meets doctor Variations: Where health models diverge Conflict: Disagreement between caregivers

11. Methods Participant Observation – Midwifery training sessions – Traditional pre and postnatal care, labor and delivery – Volunteer at Centro de Partos (birth clinic) Semi-structured and Structured Interviews – Comadronas and biomedical practitioners – Questionnaire Apprenticeship – A student of midwives

12. Topics Explored Where obstetric knowledge comes from Intents of collaboration: Biomedically-directed midwifery trainings Incorporating midwives into biomedical settings Defining the “Birth Space” Role of Caregiver

13. Results Empirical vs. non-empirical knowledge Marking birth priorities Why incorporating comadronas did not work An intermediate “birth space” Challenging a traditional model of birth

14. Conclusion Connections Variations Driving forces: a midwife’s experience and spiritual guidance and a physician’s biomedical background Conflict Midwives expect normal births, they do not treat pathologies

15. Further Implications Establishing effective partnership Sustainability of public birth clinic Intermediate space as “layover” location Ability to choose care

16. Thank you!