Recommendations for Sustainable Midwifery in Guatemala

• Author: Anna Summer,Dilys Walker
• Published date: 01 December 2018
• Date: 01 December 2018
• DOI: http://doi.org/10.1002/wmh3.282

Recommendations for Sustainable Midwifery

in Guatemala

Anna Summer and Dilys Walker

Guatemala plans to open its f‌irst government-sponsored professional midwifery school since 1960.

During the new program’s design stages, it is imperative to consider possible impediments to the

program’s sustainability. Schell’s Sustainability Framework assesses internal and external domains

to consider a program’s capacity for sustainability. We conducted in-depth interviews with

Guatemalan key decision makers and professional midwives (n ¼7) and matched pertinent open

codes from these interviews with Schell’s Sustainability Framework’s a priori domains. We analyzed

the content of the coded segments, triangulating the f‌indings with policy documents, peer-reviewed

journal articles, and gray literature to identify facilitators and impediments to midwifery’s

sustainability. Recommendations follow. Our study revealed the following internal facilitators for

sustainability: strategic planning, program adaptation, organizational capacity, and funding

stability. External facilitators such as political support and funding sustainability were also present.

The program’s poor internal communications and weak external partnerships pose signif‌icant

impediments to the program’s sustainability. Program evaluation and public health impact were not

discussed in the interviews, which merits further consideration. At the launch of this important

midwifery program, program designers must heed recommendations informed by identif‌ied

facilitators and impediments to increase midwifery’s likelihood of success in Guatemala.

KEY WORDS: professional midwifery, Latin America, skilled birth attendance, intercultural care

Introduction

Guatemala has historically recognized the need to bridge the gap between

health facilities and traditional birth attendants (TBAs) in order to improve

maternal health. In 1895, Dr. Juan Jos

e Ortega succeeded in creating La Escuela de

Comadronas or The Midwifery School that operated out of the University of San

Carlos’s medical science department. The school was the f‌irst of its kind in

Central America and boasted the f‌irst female university graduates in the country

(Quinn, Dorantes de Carranza, & Jim

enez Pinto, n.d.).

In 1903, a general nursing school was also founded in Guatemala, and in

1940, President Jorge Ubico Casta~

neda declared that the nursing and midwifery

World Medical & Health Policy, Vol. 10, No. 4, 2018

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doi: 10.1002/wmh3.282

#2018 Policy Studies Organization

schools merge, forming the Escuela Nacional de Enfermeras or the National Nursing

School. This new arrangement led to a change in curriculum. Nurses were trained

for 2 years with the option of 1 additional year of obstetric training to become

nurse midwives. Many of the original creators of the Midwifery School vocally

rejected this new model, stating that 1 year of obstetric training was insuff‌icient.

Opponents to the merge claimed that the professional midwife needed to remain a

distinct profession from nursing. Nurses work closely with doctors, and midwives

should be able to work alone in rural communities unsupervised (Quinn et al.,

n.d.). Midwifery advocates called for the midwifery school to be reopened.

This tension eventually led to a re-opening of the Midwifery School as a

separate entity in 1946 with a redesigned 3-year training program, imitating other

Latin American midwifery programs, such as that in Venezuela, Argentina, and

Mexico. This school not only clashed with the nursing school, but tensions arose

with TBAs as well, since a prominent goal of the Midwifery School was to

produce professional midwives to eventually replace TBAs (Quinn et al., n.d.).

The school was fully operational for nearly a decade before it encountered

political problems in 1955. Opportunities for professional midwife graduates

waned. Hospitals modeled after U.S. hospitals began to depend on specialized

medical doctors and professional nurses to attend births, and prohibiting

professional midwives from doing so without a physician’s supervision. Eventu-

ally, President Carlos Castillo Armas, in July 1955 declared the Nursing School to

be the only one of its kind in Guatemala. It was decided that nursing programs

with specializations in maternal health would be suff‌icient to address the

maternal health needs of the country. In 1956, the Midwifery School stopped

accepting new applicants, and the doors permanently closed in 1960 (Quinn et al.,

n.d.). Guatemala has not had a formal training or licensure program for

professional midwives since then (Chary, Dı

´az, Henderson, & Rohloff, 2013).

Thus, while the Midwifery School provided much needed education to women

and improved maternal health services, midwifery as a profession has historically

conf‌licted with physicians, nurses, and TBAs in Guatemala.

Now is a unique time for maternal health in Guatemala. With support from

UNFPA, USAID, JHPIEGO, and UNICEF, the Acuerdo Ministerial No. 538-2013,

created on December 12, 2013, legally established that the Ministry of Health

(MOH) would cooperate with universities and other institutions to create a

human resource for health: the professional midwife. This monumental govern-

mental agreement laid the groundwork for reopening the f‌irst public professional

midwifery school in country since 1960 for the purpose of providing more

Guatemalan women—particularly rural indigenous women—quality culturally

appropriate skilled birth attendance. It is widely agreed that professional

midwifery is an important component of safe motherhood strategies that can

reduce maternal morbidity and mortality (Homer et al., 2014; Horton & Astudillo,

2014; Renfrew et al., 2014; Sakala & Newburn, 2014). The State of the World’s

Midwifery in 2014, a report produced by the UNFPA, the International Confedera-

tion of Midwives, and the World Health Organization (WHO), stated that

professional midwives are crucial to overcoming barriers to accessibility,

Summer/Walker: Sustainable Midwifery in Guatemala 357