I’ve been in Guatemala for four days now. In the scheme of things, four days is nothing. I can already see that it would take years to begin to understand the complexities and subtleties of this country’s cultural workings, the fractured healthcare system, and the delicate relationship between the indigenous Mayan people and the Spanish speaking ladinos. What I know so far is how very little I know. Being comfortable in the not-knowing will be a challenge and also a blessing, as I need the ACAM midwives to be my cultural guides. This dependency on these women will create a friendship and a symbiosis as we offer each other what we can with the shared goal of helping women.
I arrived at ACAM clinic and birth center on Saturday evening after a very long night of traveling from Seattle to LAX, LAX to Guatemala City. Mary Ellen Galante, the nurse midwife from Boston who has been living down here off and on for a number of years, picked me up at the airport along with ACAM’s resident driver and handyman extraordinaire Ruben, who is becoming a fast friend. Mary Ellen is nothing short of an energetic force, a nurse midwife and MPH who has worked in midwifery and public health in Mexico, Haiti, and Guatemala. I have essentially come to take her place for the next six months, so she had been orienting me to my responsibilities here at ACAM, which is a blend of administrative work for the organization combined with clinical work and mentoring for the midwives.
The ACAM clinic and birth center opened in 2004 and is essentially a two-story building with a clinic, triage room, a reasonably well-stocked pharmacy, 3 labor and delivery rooms, a large community space for trainings and meetings, and a two-bedroom apartment for long-term foreign volunteers (that’s my space). The center is staffed 24/7 by two midwives who take 24 hour shifts and there are 14 midwives total who work at the center. ACAM also partners with a larger group of midwives (around 40 total) who care for women in the larger community and attend home births. The midwives range in age from 25 to 80, some of whom have been delivering babies for decades and decades. Some of the oldest midwives do not read or write and speak little Spanish, as their first language is Mam, one of the 23 Mayan languages. Most of the midwives speak fluent Spanish and some of them have studied through high school and are extremely bright (a group of them are taking an Excel course and inputting the organization’s data and statistics!).
The organization launched a mobile clinic program this January, which is the project I will be most heavily involved with during my time here. They chose four remote communities in the area and a group of three midwives, a Guatemalan family practice doctor (Valeria), and now myself go to each community monthly and do a clinic there for pregnant women as well as babies and children up to two years. Each team of three midwives has their own community that they continue to visit, so they can build continuity and rapport with the women there. Valeria and I will be going every week to the different communities to support the midwives and do the more complex consults. Yesterday was my first mobile clinic to a mountain community called El Rincón. The midwives have bins of medications already packed and prepared beforehand and at 6am we pack and load all the supplies onto the top of a land cruiser (as well as the portable ultrasound machine) and set off bright and early for the community. The ride was gorgeous and wild as we got further into the mountains and jungle. I felt like we were setting off into Jurassic Park, which the driver Ruben found hilarious as he was looking out for dinosaurs during our hour and a half journey.
The community is about an hour away from a health center and multiple hours away from a hospital. One of El Rincón’s community midwives, Carmen, allows us to use her home as our clinic and we set up the exam room in one bedroom of her dirt floor home and the intake room in the other. We were almost to her house when we realized the road was blocked off, so we had to carry all of our supplies uphill for about a quarter mile. The midwives set up their supplies and began welcoming the steady stream of pregnant women who arrived for their visits. Those who were new to us did an intake in Mam with our midwives, get weight and blood pressure checks, then their urine, blood sugar and hemoglobin checked, and came to see myself and Doctor Valeria for their visit. Since we didn’t know how far along in their pregnancies most of the were (and didn’t have reliable dates for many of them), we did several dating ultrasounds using second trimester measurements. For those who were closer to delivery we did ultrasound to confirm fetal position and amniotic fluid volumes.
Our first patient of the day was a 19-year-old woman having her second baby. The community midwife Carmen knew her and had calculated that she was about 28 weeks along. She was very tiny, around 100lbs, and appeared pale and fairly malnourished. Her hemoglobin was low, indicating severe anemia. She came into the exam room the midwife Carmen told us that she had strongly suggested that the patient go to the health center, as she was concerned based on her exam last week that the baby was no longer alive. The patient hadn’t felt fetal movement for over a week and her belly felt very soft and squishy, with no obvious fetal parts that felt solid. Sure enough, when we did the ultrasound, the baby was already dead and looked like it had been dead for some time, as the head was very elongated and the body appeared very abnormal. Thankfully, the patient was not yet showing signs of infection. We told her the news (translated in Mam through Carmen as the patient didn’t understand much Spanish) and explained how important it was that we get her to a hospital to induce the labor and deliver the fetus. We started her on a course of oral antibiotics and gave her iron and vitamins.
In the indigenous communities, many patients and their families have very negative feelings about going to hospitals. The hospitals are staffed by Spanish speaking “Ladinos” and indigenous people are often treated very poorly. They don’t offer indigenous translators, even though the area is so heavily populated by people who could translate. Our doctor Valeria was very concerned that this patient and her family wouldn’t agree to go to the hospital because they’ve had a lot of trouble with this before. Fortunately, this particular family was very agreeable. The patient’s Mother and Mother-in-law came to the mobile clinic to hear from the doctor and better understand the situation. We worked out with the family that we would provide the patient (and her Mother in law and son) with transportation to the nearest community health center and from there the doctor at the health center would send a referral to the hospital and send the patient there in their ambulance for treatment. We all arrived at the health center to wait with her in the waiting room until we could all discuss the case with the doctor, who was very helpful in organizing the transfer. I spoke with the nurse from the health center this morning and she told me that everything went smoothly at the hospital and the patient is expected to be discharged tomorrow. Sucess!!!
Some of the other women we saw were having their 6th, 7th, or 8th baby. The women in the remote communities don’t use any methods of family planning and don’t appear to even consider it as a possibility when asked. Over half of the women we saw had urinary tract infections and one who was at full-term had a questionable placenta previa (condition where the placenta covers the cervix and should NOT deliver vaginally due to severe bleeding risk), however that was hard to tell with our portable trans-abdominal ultrasound, so we strongly encouraged her to come to the ACAM clinic this week for a trans-vaginal ultrasound so we could tell with more accuracy. She is having her 8th baby and is planning to deliver at home with her Mother in law only, not even with a community midwife. She said she would think about coming to ACAM and that she would talk it over with her husband, but it wasn’t very convincing.
I feel like I really hit the ground running this week with the mobile clinic and seeing the myriad of challenges the midwives and doctors here in rural Guatemala face. Nevertheless, I am completely inspired by the work they are doing and truly feel that they are saving women’s lives. One of our ACAM midwives, Nancy, did a dating ultrasound with great skill and care and was able to reassure the patient in her own language, which is worth so much.
After the last couple of busy days, I’m taking the morning off today to go for a walk, explore the community, and to do some writing and yoga.
Thanks and love to all who are following my journey!
Chonte! (that’s Mam for thank you!)