An Integrated Approach to Improving Maternal Health Care in the Ixil Triangle, Quiche, Guatemala

1. An Integrated Approach to Improving Maternal Health Care in the Ixil Triangle, Quiche, Guatemala Christina Biller Fiona Clement Gia-Thanh Le Jennifer Kasper Sebalda Leshabari Kimberly A. Thiede

2. Enchantment of the World: Guatemala

3. http://tamasi.com/history/guatemala.html

4. Enchantment of the World: Guatemala

5. Enchantment of the World: Guatemala

6. http://www.public.usit.net/rfinch/santia7m.jpg

8. http://www.public.usit.net/rfinch/solola1h.jpg

9. Http://stripe.colorado.edu/~weavert/wfpfield1.html

10. History of the Armed Conflict • 36 Years: longest, bloodiest insurgency in Latin America • Human Toll • 140,000 killed (including 40,000 “disappeared”) • 200,000 children orphaned • 80,000 widowed • 1.5 million displaced (internally and in refugee camps in Mexico) *EVERY SINGLE VILLAGE IN THE IXIL TRIANGLE WAS DESTROYED!

12. History of the Armed Conflict • October 8, 1992: Repatriation of Refugees in Mexico • Peace Accords signed December 29, 1996 • Two Critical elements: • Government committed to increase spending for health and education by 50% • Accord on Identity and Rights of Indigenous Peoples • Indigenous practices respected • Guatemala “multiethnic, multilingual, pluricultural”

13. Guatemala Fertility Rate 5.1 Maternal Mortality 200/100,000 births IMR 51/1000 live births Quiche Fertility Rate 6.7 Maternal Mortality 284/100,000 births IMR 69/1000 live births 56% Women have not received tetanus vaccine Health Indicators

14. Project Goals • Reduce maternal mortality • Reduce neonatal mortality • Improve women’s health, including their mental health

15. Strategy • Improve quality of TBA services • Strengthen obstetric referral services • Improve access to emergency services • Women’s Community Health Center as forum for women to meet

18. Http://stripe.colorado.edu/~weavert/wfpfield1.html

21. Why the Ixil Triangle? • MMR and IMR higher than national average • Most maternal deaths could be prevented with better prenatal and delivery care • 30-40% IMR attributed to inadequate care during pregnancy and childbirth • If mother dies, infant has only 10% chance of survival to 1st birthday • Psychiatric morbidity may be >35%

22. Why Selected Strategy? • 80% indigenous women deliver at home with TBA • Improved TBA training can decrease MMR • Some women will need emergency services • No rural services for mental health

23. TBA Training • Culturally sensitive, linguistically appropriate course • Two 1-week intensive training courses • Apply principles from “Training Manual for Traditional Birth Attendants”, “Where Women Have No Doctor”, and other WHO materials • Monthly refresher courses

24. Training Course Topics • Antenatal care/risk assessment • Safe, sanitary labor and delivery • Emergency situations and referral • Care of the newborn • Postnatal care • Family planning

25. Methods of Teaching TBAs • Demonstration • Role-Playing • Group Discussion • Case-Presentation • Visual Aids: diagrams, posters, models, flip charts • Incorporate Mayan health beliefs wherever possible

26. Map of Ixil Triangle Chajul 7 km Pulay (site of WCHC) S. Juan Cotzal 6 km 7 km Uspantan (site of Health Center) 45 km Nebaj

27. Women’s Community Health Center (WCHC) Activities • Prenatal Care/Risk Assessment • Delivery Facility/Emergency Services including transportation • Postpartum Family Planning • Newborn Exam • Mental Health

28. Site of Delivery Based on Prenatal Risk Assessment

29. Intervention Capabilities at WCHC • Vacuum Extraction • IV Fluids/Oxytocics • Manual Removal of Placenta • Oral/Parenteral antibiotics • Anti-Hypertensives/Sedatives • Repair of Obstetrical Lacerations

30. Emergency Services • Communication and Transport • Two-way radios in specified villages, WCHC, and transport vehicle • Four-wheel drive vehicle Uspantan Village TBA WCHC

32. http://www.public.usit.net/rfinch/traje.html

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35. Network of Women in Ixil • Holistic approach to address maternal health, home life, after-effects of war • Centered at WCHC • Mental health seminars (formal and informal) in conjunction with CONAVIGUA • Weaving club/market day

36. CONAVIGUA/Human Rights • Women empowered to organize for human rights • CONAVIGUA (National Coordinator of Guatemalan Widows) established in 1988 • More than 11,000 women, primarily poor indigenous women

37. Weaving Club/Market Day • Weaving plays integral role in Mayan women’s culture • Women taught skill at early age • Guatemala one of the only countries in world where women wear decorative woven dress on daily basis • Primero coordinating market day at WCHC once a month

38. Evaluation of TBA Training Test of Knowledge • Content driven oral exam measured against supervisory guides • Demonstration of proficiency • Simulated deliveries • Observation of TBAs on home visits and deliveries

39. Evaluation of Referral System • Number of appropriate referrals to WCHC • Number of appropriate referrals to Type A Facility in Uspantan. • Measured by chart reviews • Case review and discussion of referrals in monthly TBA refresher course

40. Evaluation of Monthly Gatherings and Weaving Club • Personal satisfaction survey • Number of women per village at monthly meetings • Number of referrals to CONAVIGUA

41. Enchantment of the World: Guatemala

47. Enchantment of the World: Guatemala

48. Enchantment of the World: Guatemala

49. Project Sustainability • Partnership with MSPAS for TBA training and obstetric/prenatal care aspects • Collaboration with CONAVIGUA to empower women to actively participate in health and human rights • Weaving club/Market Day as incentive for women to gather and share/sell woven goods

50. Project Budget Contributions